Healthcare Provider Details

I. General information

NPI: 1013255769
Provider Name (Legal Business Name): PHOENIX HOUSE FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2013
Last Update Date: 01/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 W 74TH ST
NEW YORK NY
10023-2301
US

IV. Provider business mailing address

164 W 74TH ST
NEW YORK NY
10023-2301
US

V. Phone/Fax

Practice location:
  • Phone: 212-595-5810
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number7002298R
License Number StateNY

VIII. Authorized Official

Name: MARGARET OWEN WALKER
Title or Position: SOCIAL WORKER
Credential: LMSW
Phone: 212-595-5810