Healthcare Provider Details

I. General information

NPI: 1003295395
Provider Name (Legal Business Name): PHOENIX RISING THERAPEUTIC SERVICES LCSW PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2015
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5295 E VALLEY RD
ALFRED STATION NY
14803-9715
US

IV. Provider business mailing address

5295 E VALLEY RD
ALFRED STATION NY
14803-9715
US

V. Phone/Fax

Practice location:
  • Phone: 607-587-8260
  • Fax:
Mailing address:
  • Phone: 607-587-8260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR045595-1
License Number StateNY

VIII. Authorized Official

Name: MARY BETH MCDONOUGH
Title or Position: SOLE OWNER
Credential: LCSW-R
Phone: 607-587-8260