Provider Demographics
NPI:1831377563
Name:PHOENIX COUNSELING CENTER
Entity type:Organization
Organization Name:PHOENIX COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MPA
Authorized Official - Phone:704-921-3070
Mailing Address - Street 1:839 MAJESTIC CT STE 1
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5152
Mailing Address - Country:US
Mailing Address - Phone:704-396-6747
Mailing Address - Fax:704-854-4860
Practice Address - Street 1:804 N LAFAYETTE ST STE 2
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3898
Practice Address - Country:US
Practice Address - Phone:704-476-4106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX COUNSELING CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251B00000X, 251S00000X, 101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1831377563OtherNPI
NC1831377563Medicaid