Basic Information
| Provider Information | |||||||||
| NPI: | 1780348789 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHOENIX WELLNESS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 CHURCHILL DOWNS DR | ||||||||
| Address2: | |||||||||
| City: | WAXHAW | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281736627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046097334 | ||||||||
| FaxNumber: | 8556553374 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 EDGEWATER CORPORATE PKWY STE 106 | ||||||||
| Address2: | |||||||||
| City: | FORT MILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297074526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046097334 | ||||||||
| FaxNumber: | 8556553374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2021 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7046097334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 251B00000X | N | Agencies | Case Management | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QP2400X | N | Ambulatory Health Care Facilities | Clinic/Center | Prison Health | 261QV0200X | N | Ambulatory Health Care Facilities | Clinic/Center | VA | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.