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General NPI Number Information
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NPI Number | 1912434770
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Entity Type | Organization
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Legal Business Name | PHOENIX RESIDENTIAL SERVICES
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Dates
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Enumeration Date | 05/11/2017
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Last Update Date | 05/11/2017
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Provider Practice Location Address
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Address Line | 108 FRANKLIN BLVD
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City | PONTIAC
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State | MI
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Zip | 48341-1706
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Country | US
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Telephone | 248-338-3743
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Fax |
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Provider Business Mailing Address
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Address Line | 108 FRANKLIN BLVD
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City | PONTIAC
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State | MI
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Zip | 48341-1706
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Country | US
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Telephone | 248-338-3743
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DEMETRA B LEONARD
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Credential |
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Telephone | 248-338-3743
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | AS630244869
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License Number State | MI
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