Provider Demographics
NPI:1871262519
Name:PHOENIX COUNSELING SERVICES LLC
Entity type:Organization
Organization Name:PHOENIX COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DELAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:469-290-2353
Mailing Address - Street 1:8700 US HIGHWAY 380 STE 502
Mailing Address - Street 2:
Mailing Address - City:CROSSROADS
Mailing Address - State:TX
Mailing Address - Zip Code:76227-2661
Mailing Address - Country:US
Mailing Address - Phone:469-290-2353
Mailing Address - Fax:
Practice Address - Street 1:8700 US HIGHWAY 380 STE 502
Practice Address - Street 2:
Practice Address - City:CROSSROADS
Practice Address - State:TX
Practice Address - Zip Code:76227-2661
Practice Address - Country:US
Practice Address - Phone:469-290-2353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-07
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1194146050Medicaid