Provider Demographics
NPI:1245765874
Name:MUSSALOW, PHOENIX (MA, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:PHOENIX
Middle Name:
Last Name:MUSSALOW
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6693 N CHESTNUT ST STE 235
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3900
Mailing Address - Country:US
Mailing Address - Phone:330-296-3700
Mailing Address - Fax:
Practice Address - Street 1:2562 GRAHAM RD
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-3504
Practice Address - Country:US
Practice Address - Phone:276-200-8769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2020-08-06
Deactivation Date:2017-08-09
Deactivation Code:
Reactivation Date:2020-08-05
Provider Licenses
StateLicense IDTaxonomies
OHC.1600825101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health