Provider Demographics
NPI:1780222976
Name:PHOENIX COUNSELING & TRAUMA TREATMENT CENTER, LLC
Entity Type:Organization
Organization Name:PHOENIX COUNSELING & TRAUMA TREATMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:KENT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:856-300-7770
Mailing Address - Street 1:4601 ASCHER RD
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08361-7601
Mailing Address - Country:US
Mailing Address - Phone:856-300-7770
Mailing Address - Fax:
Practice Address - Street 1:727 E LANDIS AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-8001
Practice Address - Country:US
Practice Address - Phone:856-300-7770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty