Provider Demographics
NPI:1720472244
Name:PHOENIX HEALTHCARE OF VIRGINIA LLC
Entity Type:Organization
Organization Name:PHOENIX HEALTHCARE OF VIRGINIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SONDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-898-8812
Mailing Address - Street 1:904 PRINCESS ANNE ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-5801
Mailing Address - Country:US
Mailing Address - Phone:540-898-8812
Mailing Address - Fax:
Practice Address - Street 1:904 PRINCESS ANNE ST
Practice Address - Street 2:SUITE 301
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-5801
Practice Address - Country:US
Practice Address - Phone:540-898-8812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003951103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty