Provider Demographics
NPI:1558978932
Name:PHOENIX PEDIATRIC THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:PHOENIX PEDIATRIC THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:B
Authorized Official - Last Name:PHOENIX
Authorized Official - Suffix:
Authorized Official - Credentials:MS,CCC-SLP
Authorized Official - Phone:240-425-8605
Mailing Address - Street 1:12806 SHOLTON ST
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-1715
Mailing Address - Country:US
Mailing Address - Phone:240-620-5688
Mailing Address - Fax:
Practice Address - Street 1:16201 TRADE ZONE AVE STE 106
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-8758
Practice Address - Country:US
Practice Address - Phone:240-425-8605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty