Provider Demographics
NPI:1336728724
Name:PHOENIX DOMUS
Entity Type:Organization
Organization Name:PHOENIX DOMUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MCCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MED, CHES
Authorized Official - Phone:814-934-6513
Mailing Address - Street 1:114 BEECH AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-4235
Mailing Address - Country:US
Mailing Address - Phone:814-502-5157
Mailing Address - Fax:
Practice Address - Street 1:114 BEECH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-4235
Practice Address - Country:US
Practice Address - Phone:814-502-5157
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-05
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA077037Medicaid