Provider Demographics
NPI:1346600293
Name:THE PHOENIX RECOVERY & COUNSELING CENTER - RIVERDALE
Entity Type:Organization
Organization Name:THE PHOENIX RECOVERY & COUNSELING CENTER - RIVERDALE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-571-6798
Mailing Address - Street 1:5133 S 1500 W
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84405-3926
Mailing Address - Country:US
Mailing Address - Phone:801-392-0895
Mailing Address - Fax:801-619-2016
Practice Address - Street 1:5133 S 1500 W
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:UT
Practice Address - Zip Code:84405-3926
Practice Address - Country:US
Practice Address - Phone:801-392-0895
Practice Address - Fax:801-619-2016
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE PHOENIX RECOVERY CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT19186101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X, 103K00000X, 261QM0850X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health