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General NPI Number Information
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NPI Number | 1548789860
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Entity Type | Organization
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Legal Business Name | PHOENIX FAMILY RESOURCE CENTER
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Dates
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Enumeration Date | 09/18/2017
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Last Update Date | 09/18/2017
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Provider Practice Location Address
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Address Line | 4284 MEMORIAL DR STE D
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City | DECATUR
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State | GA
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Zip | 30032-1220
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Country | US
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Telephone | 678-358-5099
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Fax | 770-388-7763
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Provider Business Mailing Address
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Address Line | 1701 LIMESTONE TER
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City | LITHONIA
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State | GA
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Zip | 30058-3715
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Country | US
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Telephone | 678-358-5099
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Fax | 770-388-7763
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | MRS. BRENDA LOUISE GRIFFIN
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Credential | LPC, CACII, MAC CCS
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Telephone | 678-358-5099
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 00242918
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License Number State | GA
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