Provider Demographics
NPI:1548789860
Name:PHOENIX FAMILY RESOURCE CENTER
Entity Type:Organization
Organization Name:PHOENIX FAMILY RESOURCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, CACII, MAC CCS
Authorized Official - Phone:678-358-5099
Mailing Address - Street 1:1701 LIMESTONE TER
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-3715
Mailing Address - Country:US
Mailing Address - Phone:678-358-5099
Mailing Address - Fax:770-388-7763
Practice Address - Street 1:4284 MEMORIAL DR STE D
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1220
Practice Address - Country:US
Practice Address - Phone:678-358-5099
Practice Address - Fax:770-388-7763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-18
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00242918324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility