Provider Demographics
NPI:1134759186
Name:PHOENIX REBELLION THERAPY, LLC
Entity type:Organization
Organization Name:PHOENIX REBELLION THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/EXEC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROD
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:385-231-8387
Mailing Address - Street 1:4516 S 700 E STE 360
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-8317
Mailing Address - Country:US
Mailing Address - Phone:385-231-8387
Mailing Address - Fax:
Practice Address - Street 1:4516 S 700 E STE 360
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-8317
Practice Address - Country:US
Practice Address - Phone:385-231-8387
Practice Address - Fax:385-240-3843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-17
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty