Healthcare Provider Details

I. General information

NPI: 1033247945
Provider Name (Legal Business Name): PHOENIX THERAPEUTIC FOUNDATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5602 BALTIMORE NATIONAL PIKE SUITE 700
BALTIMORE MD
21228-1411
US

IV. Provider business mailing address

5602 BALTIMORE NATIONAL PIKE SUITE 700
BALTIMORE MD
21228-1411
US

V. Phone/Fax

Practice location:
  • Phone: 410-744-9100
  • Fax: 410-747-0226
Mailing address:
  • Phone: 410-744-9100
  • Fax: 410-747-0226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCA149
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC1148
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberG08008
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11349
License Number StateMD
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberD0016432
License Number StateMD

VIII. Authorized Official

Name: AMR A ELBESHIR
Title or Position: PROGRAM DIRECTOR CEO
Credential: M.A.
Phone: 410-744-9100