MEDICARE: PHOENIX HOUSEOF NY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	069641	NY

General Provider Information

NPI Number	:	1710122536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX HOUSEOF NY, INC.

Provider Business Mailing Address
First Line	:	283 SPRINGS FIREPLACE RD
Second Line	:
City	:	EAST HAMPTON
State	:	NY
Zip	:	11937-4823
Country	:	US
Telephone Number	:	631-329-0373
Fax Number	:	631-907-9345

Provider Business Practice Location Address
First Line	:	283 SPRINGS FIREPLACE RD
Second Line	:
City	:	EAST HAMPTON
State	:	NY
Zip	:	11937-4823
Country	:	US
Telephone Number	:	631-329-0373
Fax Number	:	631-907-9345

Authorized Official
Title or Position	:	SOCIAL WORKER
Name	:	MS. MICHELE ROTHAR
Credential	:	LCSW
Telephone Number	:	631-329-0373

Provider Enumeration Date	:	12/08/2008
Last Update Date	:	12/08/2008

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