Provider Demographics
NPI:1710122536
Name:PHOENIX HOUSEOF NY, INC.
Entity Type:Organization
Organization Name:PHOENIX HOUSEOF NY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTHAR
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:631-329-0373
Mailing Address - Street 1:283 SPRINGS FIREPLACE RD
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11937-4823
Mailing Address - Country:US
Mailing Address - Phone:631-329-0373
Mailing Address - Fax:631-907-9345
Practice Address - Street 1:283 SPRINGS FIREPLACE RD
Practice Address - Street 2:
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937-4823
Practice Address - Country:US
Practice Address - Phone:631-329-0373
Practice Address - Fax:631-907-9345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0696411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty