Provider Demographics
NPI:1083155667
Name:PHOENIX RISING COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:PHOENIX RISING COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:AUNDRETTA
Authorized Official - Middle Name:MYKEL
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:678-824-2010
Mailing Address - Street 1:863 FLAT SHOALS RD SE
Mailing Address - Street 2:SUITE C #149
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-6633
Mailing Address - Country:US
Mailing Address - Phone:678-824-2010
Mailing Address - Fax:888-705-0482
Practice Address - Street 1:200 COLSER DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-0991
Practice Address - Country:US
Practice Address - Phone:678-824-2010
Practice Address - Fax:888-705-0482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW005912251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health