Provider Demographics
NPI:1922252089
Name:PHASEBDEVELOPMENT
Entity Type:Organization
Organization Name:PHASEBDEVELOPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:REDMON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MED
Authorized Official - Phone:646-512-1620
Mailing Address - Street 1:138 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-2119
Mailing Address - Country:US
Mailing Address - Phone:646-512-1620
Mailing Address - Fax:
Practice Address - Street 1:138 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-2119
Practice Address - Country:US
Practice Address - Phone:646-512-1620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239456258320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities