Provider Demographics
NPI:1235263427
Name:PHOENIX COUNSELING, LTD
Entity Type:Organization
Organization Name:PHOENIX COUNSELING, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:KUYKENDALL
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:608-825-6711
Mailing Address - Street 1:1500 WEST MAIN ST. SUITE 300
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590
Mailing Address - Country:US
Mailing Address - Phone:608-825-6711
Mailing Address - Fax:608-834-6499
Practice Address - Street 1:1500 WEST MAIN STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590
Practice Address - Country:US
Practice Address - Phone:608-825-6711
Practice Address - Fax:608-834-6499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42226100Medicaid