Provider Demographics
NPI:1033263694
Name:CHRYSALIS SHELTER FOR VICTIMS OF DOMESTIC VIOLENCE INC
Entity Type:Organization
Organization Name:CHRYSALIS SHELTER FOR VICTIMS OF DOMESTIC VIOLENCE INC
Other - Org Name:CHRYSALIS
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLAHR
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:602-955-9059
Mailing Address - Street 1:2055 WEST NORTHERN AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-5157
Mailing Address - Country:US
Mailing Address - Phone:602-955-9059
Mailing Address - Fax:602-955-0165
Practice Address - Street 1:2055 WEST NORTHERN AVENUE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-5157
Practice Address - Country:US
Practice Address - Phone:602-955-9059
Practice Address - Fax:602-955-0165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4093305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service