Healthcare Provider Details

I. General information

NPI: 1457002438
Provider Name (Legal Business Name): PHOENIX FREEDOM FOUNDATION OF MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

14207 KATHLEEN LN
BRANDYWINE MD
20613-3006
US

IV. Provider business mailing address

2957 FESTIVAL WAY STE 123
WALDORF MD
20601-2959
US

V. Phone/Fax

Practice location:
  • Phone: 240-443-1803
  • Fax:
Mailing address:
  • Phone: 240-443-1803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: DR. QUORNELIA A HYPOLITE
Title or Position: PROGRAM DIRECTOR/CEO
Credential:
Phone: 240-443-1803