Provider Demographics
NPI:1063037364
Name:PHOENIX HEALTH PROFESSIONAL GROUP, LLC
Entity Type:Organization
Organization Name:PHOENIX HEALTH PROFESSIONAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:GOLOSKIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-771-1154
Mailing Address - Street 1:1301 ATWOOD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919-4933
Mailing Address - Country:US
Mailing Address - Phone:617-771-1154
Mailing Address - Fax:
Practice Address - Street 1:99 WAYLAND AVE STE 100
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4314
Practice Address - Country:US
Practice Address - Phone:617-771-1154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Multi-Specialty