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General NPI Number Information
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NPI Number | 1700297876
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Entity Type | Organization
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Legal Business Name | PHOENIX LLC
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Dates
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Enumeration Date | 05/12/2014
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Last Update Date | 01/20/2015
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Provider Practice Location Address
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Address Line | 4919 BRAMBLETON AVE
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City | ROANOKE
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State | VA
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Zip | 24018-4149
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Country | US
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Telephone | 540-685-4298
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Fax | 540-685-4299
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Provider Business Mailing Address
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Address Line | 4919 BRAMBLETON AVE
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City | ROANOKE
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State | VA
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Zip | 24018-4149
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Country | US
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Telephone | 540-685-4298
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Fax | 540-685-4299
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Authorized Official
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Title or Position | OWNER
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Name | ASHLEY CALLAHAN
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Credential | PHD
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Telephone | 540-685-4298
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 1910-03-001
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License Number State | VA
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