Provider Demographics
NPI:1659950343
Name:PHOENIX RISING WELLNESS CENTER OF CORPUS CHRISTI, PLLC
Entity Type:Organization
Organization Name:PHOENIX RISING WELLNESS CENTER OF CORPUS CHRISTI, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:IKONOMOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:PH-D, LPC
Authorized Official - Phone:361-425-4684
Mailing Address - Street 1:PO BOX 181459
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78480-1459
Mailing Address - Country:US
Mailing Address - Phone:361-739-1679
Mailing Address - Fax:
Practice Address - Street 1:6000 S STAPLES ST STE 406
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-2952
Practice Address - Country:US
Practice Address - Phone:361-739-1679
Practice Address - Fax:361-239-4286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty