Provider Demographics
NPI:1043324353
Name:PHOENIX, RIVER JANE (LCPC)
Entity type:Individual
Prefix:
First Name:RIVER
Middle Name:JANE
Last Name:PHOENIX
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JANE
Other - Last Name:WATEROUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:225 N WRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-4749
Mailing Address - Country:US
Mailing Address - Phone:630-885-3443
Mailing Address - Fax:
Practice Address - Street 1:225 N WRIGHT ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-4749
Practice Address - Country:US
Practice Address - Phone:630-885-3443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005544101YP2500X
IL180-005544101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional