Provider Demographics
NPI:1225237340
Name:PHOENIX INTERFAITH COUNSELING
Entity Type:Organization
Organization Name:PHOENIX INTERFAITH COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ELDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-532-0777
Mailing Address - Street 1:555 W GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-8763
Mailing Address - Country:US
Mailing Address - Phone:602-532-0777
Mailing Address - Fax:602-532-0999
Practice Address - Street 1:4201 N 16TH ST STE 250
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5375
Practice Address - Country:US
Practice Address - Phone:602-532-0777
Practice Address - Fax:602-532-0999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH2448251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ948458Medicaid
AZWMBMTMedicare PIN