Provider Demographics
NPI:1356168991
Name:PHOENIX RISING TEEN DEVELOPMENT
Entity type:Organization
Organization Name:PHOENIX RISING TEEN DEVELOPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:KATHRYN
Authorized Official - Last Name:ROUNSAVELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:719-648-6092
Mailing Address - Street 1:2616 FLINTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4425
Mailing Address - Country:US
Mailing Address - Phone:719-648-6092
Mailing Address - Fax:
Practice Address - Street 1:2616 FLINTRIDGE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4425
Practice Address - Country:US
Practice Address - Phone:719-425-5421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-24
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty