Provider Demographics
NPI:1285301606
Name:PHOENIX, QUASAR CHARLI (LCPC-C)
Entity type:Individual
Prefix:
First Name:QUASAR
Middle Name:CHARLI
Last Name:PHOENIX
Suffix:
Gender:F
Credentials:LCPC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 HIGH ST APT 201
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-2643
Mailing Address - Country:US
Mailing Address - Phone:207-468-2973
Mailing Address - Fax:
Practice Address - Street 1:84 HIGH ST APT 201
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-2643
Practice Address - Country:US
Practice Address - Phone:207-383-5672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101200000X, 221700000X, 225600000X, 225A00000X
MEXL6198101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101200000XBehavioral Health & Social Service ProvidersDrama Therapist
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist