Provider Demographics
NPI:1003295395
Name:PHOENIX RISING THERAPEUTIC SERVICES LCSW PC
Entity Type:Organization
Organization Name:PHOENIX RISING THERAPEUTIC SERVICES LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:607-587-8260
Mailing Address - Street 1:5295 E VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:ALFRED STATION
Mailing Address - State:NY
Mailing Address - Zip Code:14803-9715
Mailing Address - Country:US
Mailing Address - Phone:607-587-8260
Mailing Address - Fax:
Practice Address - Street 1:5295 E VALLEY RD
Practice Address - Street 2:
Practice Address - City:ALFRED STATION
Practice Address - State:NY
Practice Address - Zip Code:14803-9715
Practice Address - Country:US
Practice Address - Phone:607-587-8260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR045595-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty