Healthcare Provider Details

I. General information

NPI: 1033489109
Provider Name (Legal Business Name): PHOENIX PSYCHIATRIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2012
Last Update Date: 01/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 JEREMIAH SULLIVAN DR
FALL RIVER MA
02721
US

IV. Provider business mailing address

3338 N MAIN ST
FALL RIVER MA
02720-1609
US

V. Phone/Fax

Practice location:
  • Phone: 774-644-5629
  • Fax: 508-678-8100
Mailing address:
  • Phone: 508-676-5514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number206747
License Number StateMA

VIII. Authorized Official

Name: MS. EWA M. CONROY
Title or Position: OWNER
Credential: APRN
Phone: 508-676-5514