Provider Demographics
NPI:1720572043
Name:PHOENIX WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:PHOENIX WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:KINNAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, NCC, LPC
Authorized Official - Phone:480-653-8434
Mailing Address - Street 1:2060 W WHISPERING WIND DR STE 270
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-2869
Mailing Address - Country:US
Mailing Address - Phone:480-653-8434
Mailing Address - Fax:623-258-4077
Practice Address - Street 1:2060 W WHISPERING WIND DR STE 270
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085
Practice Address - Country:US
Practice Address - Phone:480-653-8434
Practice Address - Fax:623-258-4077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-20
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOTC8779OtherOUTPATIENT TREATMENT CENTER