Provider Demographics
NPI:1093277048
Name:RISING PHOENIX COUNSELING, LLC
Entity Type:Organization
Organization Name:RISING PHOENIX COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:386-837-2362
Mailing Address - Street 1:130 SUNRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-3849
Mailing Address - Country:US
Mailing Address - Phone:386-837-2362
Mailing Address - Fax:
Practice Address - Street 1:366 E GRAVES AVE STE D
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-5266
Practice Address - Country:US
Practice Address - Phone:407-777-2596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty