Provider Demographics
NPI:1033247945
Name:PHOENIX THERAPEUTIC FOUNDATION, INC
Entity Type:Organization
Organization Name:PHOENIX THERAPEUTIC FOUNDATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMR
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELBESHIR
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:410-744-9100
Mailing Address - Street 1:5602 BALTIMORE NATIONAL PIKE
Mailing Address - Street 2:SUITE 700
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-1411
Mailing Address - Country:US
Mailing Address - Phone:410-744-9100
Mailing Address - Fax:410-747-0226
Practice Address - Street 1:5602 BALTIMORE NATIONAL PIKE
Practice Address - Street 2:SUITE 700
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-1411
Practice Address - Country:US
Practice Address - Phone:410-744-9100
Practice Address - Fax:410-747-0226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA149101YA0400X
MDLC1148101YM0800X
MDG08008104100000X
MD113491041C0700X
MDD0016432251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD403344200Medicaid