Provider Demographics
NPI:1801214986
Name:PHOENIX PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:PHOENIX PROFESSIONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:860-680-9440
Mailing Address - Street 1:29 CONNECTICUT BLVD
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3008
Mailing Address - Country:US
Mailing Address - Phone:860-778-1257
Mailing Address - Fax:
Practice Address - Street 1:29 CONNECTICUT BLVD
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3008
Practice Address - Country:US
Practice Address - Phone:860-778-1257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-04
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002311251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008046849Medicaid