Provider Demographics
NPI:1235803636
Name:MISTY MOUNTAIN PHOENIX RISING LLC
Entity Type:Organization
Organization Name:MISTY MOUNTAIN PHOENIX RISING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMFT
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROZELLE
Authorized Official - Suffix:
Authorized Official - Credentials:MA MFT
Authorized Official - Phone:818-602-3680
Mailing Address - Street 1:22314 CANONES CIRCLE
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91350-2244
Mailing Address - Country:US
Mailing Address - Phone:818-602-3680
Mailing Address - Fax:661-309-4677
Practice Address - Street 1:23550 LYONS AVE.
Practice Address - Street 2:SUITE 211
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-9132
Practice Address - Country:US
Practice Address - Phone:818-602-3680
Practice Address - Fax:661-309-4677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty