Healthcare Provider Details

I. General information

NPI: 1568174126
Provider Name (Legal Business Name): PHOENIX HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2022
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5616 PARK HEIGHTS AVE
BALTIMORE MD
21215-3969
US

IV. Provider business mailing address

5616 PARK HEIGHTS AVE
BALTIMORE MD
21215-3969
US

V. Phone/Fax

Practice location:
  • Phone: 443-878-1111
  • Fax:
Mailing address:
  • Phone: 443-878-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. NICOLE LIVELY
Title or Position: COO
Credential: MBA
Phone: 443-631-3303