Provider Demographics
NPI:1093974537
Name:PHOENIX COUNSELING OF GASTON LINCOLN
Entity Type:Organization
Organization Name:PHOENIX COUNSELING OF GASTON LINCOLN
Other - Org Name:PHOENIX COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:MA MPA
Authorized Official - Phone:704-921-3070
Mailing Address - Street 1:4007 WILD NURSERY CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-5345
Mailing Address - Country:US
Mailing Address - Phone:704-921-3070
Mailing Address - Fax:704-921-3066
Practice Address - Street 1:917 1ST ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3958
Practice Address - Country:US
Practice Address - Phone:704-921-3070
Practice Address - Fax:704-921-3066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YA0400X, 101YM0800X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty