Provider Demographics
NPI:1467609388
Name:PHOENIX CENTER FOR HEALING P.A.
Entity Type:Organization
Organization Name:PHOENIX CENTER FOR HEALING P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTER AGENT FLORIDA CORP
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:HAFNER
Authorized Official - Suffix:
Authorized Official - Credentials:MENTAL HEALTH COUNSE
Authorized Official - Phone:786-236-7927
Mailing Address - Street 1:14875 SW 238TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-8702
Mailing Address - Country:US
Mailing Address - Phone:786-236-7927
Mailing Address - Fax:305-257-0040
Practice Address - Street 1:11060 N KENDALL DR
Practice Address - Street 2:SUITE 7
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-1272
Practice Address - Country:US
Practice Address - Phone:305-345-3498
Practice Address - Fax:305-257-0040
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX CENTER FOR HEALING P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCAP 2344101YA0400X
FLMH7474101YM0800X
101YP1600X, 103G00000X, 106H00000X, 174400000X
FLSS888103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty