Provider Demographics
NPI:1336642958
Name:PROJECT180-PHOENIX, LLC
Entity Type:Organization
Organization Name:PROJECT180-PHOENIX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSALYN
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MAC, CADC, MS
Authorized Official - Phone:311-261-7785
Mailing Address - Street 1:1507 E 53RD ST UNIT 247
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4573
Mailing Address - Country:US
Mailing Address - Phone:312-617-7857
Mailing Address - Fax:
Practice Address - Street 1:6736 W CARSON RD
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-7024
Practice Address - Country:US
Practice Address - Phone:602-888-6779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5362261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health