Healthcare Provider Details

I. General information

NPI: 1063037364
Provider Name (Legal Business Name): PHOENIX HEALTH PROFESSIONAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 WAYLAND AVE STE 100
PROVIDENCE RI
02906-4314
US

IV. Provider business mailing address

1301 ATWOOD AVE STE 100
JOHNSTON RI
02919-4933
US

V. Phone/Fax

Practice location:
  • Phone: 617-771-1154
  • Fax:
Mailing address:
  • Phone: 617-771-1154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JOEL K GOLOSKIE
Title or Position: COUNSEL
Credential:
Phone: 617-771-1154