Provider Demographics
NPI:1275154627
Name:PHOENIX ROSE MARRIAGE AND FAMILY THERAPY PLLC
Entity Type:Organization
Organization Name:PHOENIX ROSE MARRIAGE AND FAMILY THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BREANA
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:516-757-3598
Mailing Address - Street 1:26 MARGARET DR
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-1535
Mailing Address - Country:US
Mailing Address - Phone:516-757-3598
Mailing Address - Fax:
Practice Address - Street 1:26 MARGARET DR
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-1535
Practice Address - Country:US
Practice Address - Phone:516-757-3598
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty