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General NPI Number Information
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NPI Number | 1003295395
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Entity Type | Organization
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Legal Business Name | PHOENIX RISING THERAPEUTIC SERVICES LCSW PC
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Dates
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Enumeration Date | 05/20/2015
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Last Update Date | 05/20/2015
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Provider Practice Location Address
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Address Line | 5295 E VALLEY RD
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City | ALFRED STATION
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State | NY
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Zip | 14803-9715
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Country | US
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Telephone | 607-587-8260
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Fax |
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Provider Business Mailing Address
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Address Line | 5295 E VALLEY RD
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City | ALFRED STATION
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State | NY
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Zip | 14803-9715
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Country | US
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Telephone | 607-587-8260
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Fax |
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Authorized Official
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Title or Position | SOLE OWNER
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Name | MARY BETH MCDONOUGH
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Credential | LCSW-R
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Telephone | 607-587-8260
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | R045595-1
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License Number State | NY
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