Provider Demographics
NPI:1396845004
Name:PHOENIX COUNSELING CENTER
Entity Type:Organization
Organization Name:PHOENIX COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MPA
Authorized Official - Phone:704-491-0829
Mailing Address - Street 1:839 MAJESTIC CT STE 1
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5152
Mailing Address - Country:US
Mailing Address - Phone:704-396-6747
Mailing Address - Fax:704-671-2553
Practice Address - Street 1:322 MCBEE ST
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-2819
Practice Address - Country:US
Practice Address - Phone:704-240-9453
Practice Address - Fax:704-240-4603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-23
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-036-214101YA0400X, 320800000X, 324500000X
NC101YM0800X
NCMHL 036-214251B00000X, 251S00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301469PMedicaid
NC8301469Medicaid
NC8301469GMedicaid
NC8301469BMedicaid
NC6005727Medicaid
NC8301469QMedicaid