Provider Demographics
NPI:1396387445
Name:PHOENIX, WENDI ELLEN
Entity Type:Individual
Prefix:
First Name:WENDI
Middle Name:ELLEN
Last Name:PHOENIX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1837 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GUN BARREL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:75156-4401
Mailing Address - Country:US
Mailing Address - Phone:903-910-2294
Mailing Address - Fax:
Practice Address - Street 1:1345 RIVER BEND DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-6943
Practice Address - Country:US
Practice Address - Phone:214-743-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72824101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional