Provider Demographics
NPI:1639348154
Name:PHOENIX, EILEEN SUSAN (LAC)
Entity Type:Individual
Prefix:MS
First Name:EILEEN
Middle Name:SUSAN
Last Name:PHOENIX
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 CLARKE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-1112
Mailing Address - Country:US
Mailing Address - Phone:718-619-6808
Mailing Address - Fax:718-667-5365
Practice Address - Street 1:134 CLARKE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-1112
Practice Address - Country:US
Practice Address - Phone:718-619-6808
Practice Address - Fax:718-667-5365
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003657171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist