Provider Demographics
NPI:1790804292
Name:PHOENIX HOUSE OF NEW ENGLAND
Entity Type:Organization
Organization Name:PHOENIX HOUSE OF NEW ENGLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:REYNARD
Authorized Official - Middle Name:LORIN
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MS LMFT
Authorized Official - Phone:401-783-0782
Mailing Address - Street 1:1058 KINGSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-2487
Mailing Address - Country:US
Mailing Address - Phone:401-783-0782
Mailing Address - Fax:401-783-1154
Practice Address - Street 1:1058 KINGSTOWN RD
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-2487
Practice Address - Country:US
Practice Address - Phone:401-783-0782
Practice Address - Fax:401-783-1154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00100251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health