Provider Demographics
NPI:1417479056
Name:PHOENIX RISINGS COUNSELING CENTER LLC
Entity Type:Organization
Organization Name:PHOENIX RISINGS COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNNE
Authorized Official - Middle Name:CHANTEL
Authorized Official - Last Name:HOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW LCADC
Authorized Official - Phone:973-393-0312
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-0358
Mailing Address - Country:US
Mailing Address - Phone:770-568-0619
Mailing Address - Fax:973-629-1741
Practice Address - Street 1:50 UNION AVE STE 804B
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-5221
Practice Address - Country:US
Practice Address - Phone:770-568-0619
Practice Address - Fax:973-629-1741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-14
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00259900101YA0400X
NJ44SC057179001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty