Provider Demographics
NPI:1790844520
Name:PHOENIX HOUSE FOUNDATION
Entity Type:Organization
Organization Name:PHOENIX HOUSE FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:MS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:BERNABO
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:718-726-8484
Mailing Address - Street 1:9328 85TH RD
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-1418
Mailing Address - Country:US
Mailing Address - Phone:718-846-8187
Mailing Address - Fax:
Practice Address - Street 1:3411 VERNON BLVD
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11106-5121
Practice Address - Country:US
Practice Address - Phone:718-726-8484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY414715-1324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility