Provider Demographics
NPI:1871206722
Name:PHOENIX HEALTH SERVICES
Entity type:Organization
Organization Name:PHOENIX HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:443-878-1111
Mailing Address - Street 1:5616 PARK HEIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-3969
Mailing Address - Country:US
Mailing Address - Phone:443-631-3303
Mailing Address - Fax:
Practice Address - Street 1:5611 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-3541
Practice Address - Country:US
Practice Address - Phone:443-878-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility