=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336464965
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIX HOUSE FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2010
-----------------------------------------------------
Last Update Date | 04/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 998 CROOKED HILL RD BUILDING 5
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11717-1019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-306-5740
-----------------------------------------------------
Fax | 631-306-5885
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 998 CROOKED HILL RD BUILDING 5
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11717-1019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-306-5740
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR COUNSELOR
-----------------------------------------------------
Name | MR. ELAN DANIEL ROBIN
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 631-306-5770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 080833-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------