Provider Demographics
NPI:1750672937
Name:PHOENIX, UNKNOWN (LPC, CACIII)
Entity Type:Individual
Prefix:
First Name:UNKNOWN
Middle Name:
Last Name:PHOENIX
Suffix:
Gender:F
Credentials:LPC, CACIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3716
Mailing Address - Country:US
Mailing Address - Phone:970-402-8543
Mailing Address - Fax:970-493-9113
Practice Address - Street 1:1220 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3716
Practice Address - Country:US
Practice Address - Phone:970-402-8543
Practice Address - Fax:970-493-9113
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5254101YA0400X
CO3067101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)