Provider Demographics
NPI:1689748428
Name:PHOENIX BEHAVIORAL HEALTH SERVICES
Entity Type:Organization
Organization Name:PHOENIX BEHAVIORAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIEDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-736-6135
Mailing Address - Street 1:PO BOX 1081
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19903-1081
Mailing Address - Country:US
Mailing Address - Phone:302-736-6135
Mailing Address - Fax:302-736-0172
Practice Address - Street 1:1059 S BRADFORD ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-4141
Practice Address - Country:US
Practice Address - Phone:302-736-6135
Practice Address - Fax:302-736-0172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000022273Medicaid
DE1000022273Medicaid