Provider Demographics
NPI:1841172087
Name:UNLEASHED PHOENIX CORP
Entity type:Organization
Organization Name:UNLEASHED PHOENIX CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-216-1237
Mailing Address - Street 1:11 E SUPERIOR ST STE 543
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2089
Mailing Address - Country:US
Mailing Address - Phone:218-409-6576
Mailing Address - Fax:
Practice Address - Street 1:11 E SUPERIOR ST STE 543
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2089
Practice Address - Country:US
Practice Address - Phone:218-409-6576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-21
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health