Provider Demographics
NPI:1457002438
Name:PHOENIX FREEDOM FOUNDATION OF MD, INC
Entity Type:Organization
Organization Name:PHOENIX FREEDOM FOUNDATION OF MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:QUORNELIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HYPOLITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-443-1803
Mailing Address - Street 1:2957 FESTIVAL WAY STE 123
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-2959
Mailing Address - Country:US
Mailing Address - Phone:240-443-1803
Mailing Address - Fax:
Practice Address - Street 1:14207 KATHLEEN LN
Practice Address - Street 2:
Practice Address - City:BRANDYWINE
Practice Address - State:MD
Practice Address - Zip Code:20613-3006
Practice Address - Country:US
Practice Address - Phone:240-443-1803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty
No253Z00000XAgenciesIn Home Supportive Care
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, ChildGroup - Single Specialty