Provider Demographics
NPI:1235581240
Name:PHOENIX THERAPY
Entity Type:Organization
Organization Name:PHOENIX THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:714-473-1043
Mailing Address - Street 1:12530 10TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-3520
Mailing Address - Country:US
Mailing Address - Phone:714-473-1043
Mailing Address - Fax:
Practice Address - Street 1:12530 10TH ST STE D
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-3520
Practice Address - Country:US
Practice Address - Phone:714-473-1043
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-01
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24744251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health