Healthcare Provider Details

I. General information

NPI: 1588389274
Provider Name (Legal Business Name): PHA HOLISTIC HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2022
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E LOMBARD ST STE 810
BALTIMORE MD
21202-3231
US

IV. Provider business mailing address

300 E LOMBARD ST STE 810
BALTIMORE MD
21202-3231
US

V. Phone/Fax

Practice location:
  • Phone: 717-654-9007
  • Fax:
Mailing address:
  • Phone: 717-654-9007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN W THOMAS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 717-654-9007