Provider Demographics
NPI:1629320478
Name:PHOENIX ASSOCIATES COUNSELING SERVICES, INC.
Entity Type:Organization
Organization Name:PHOENIX ASSOCIATES COUNSELING SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:CUDMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-338-0311
Mailing Address - Street 1:3001 W 5TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-8900
Mailing Address - Country:US
Mailing Address - Phone:817-338-0311
Mailing Address - Fax:817-332-9075
Practice Address - Street 1:801 ROAD TO SIX FLAGS W STE 132
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-2600
Practice Address - Country:US
Practice Address - Phone:817-795-3030
Practice Address - Fax:817-795-3099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1656-3039251S00000X, 261QM0801X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX212971001Medicaid