Provider Demographics
NPI:1639636335
Name:PHOENIX HOUSES OF TEXAS, INC
Entity type:Organization
Organization Name:PHOENIX HOUSES OF TEXAS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:DREW
Authorized Official - Middle Name:
Authorized Official - Last Name:DUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-932-5050
Mailing Address - Street 1:1910 PACIFIC AVE STE 10500
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-4591
Mailing Address - Country:US
Mailing Address - Phone:214-920-1628
Mailing Address - Fax:214-351-0967
Practice Address - Street 1:2803 MOSSROCK DRIVE
Practice Address - Street 2:OFFICES 113, 122; MEETING ROOMS 3 & 4, ROOMS 103 & 106
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-5131
Practice Address - Country:US
Practice Address - Phone:512-440-0613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-28
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX865-4902OtherTEXAS DEPARTMENT OF STATE HEALTH SERVICES
TX396608701Medicaid