Provider Demographics
NPI:1720624802
Name:PHOENIX WELLNESS SERVICES LLC
Entity Type:Organization
Organization Name:PHOENIX WELLNESS SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:THALIA
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:240-522-9139
Mailing Address - Street 1:10 E NORTH AVE STE 10
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-4886
Mailing Address - Country:US
Mailing Address - Phone:240-242-9302
Mailing Address - Fax:240-308-8646
Practice Address - Street 1:10 E NORTH AVE STE 10
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-4886
Practice Address - Country:US
Practice Address - Phone:240-242-9302
Practice Address - Fax:240-308-8646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-22
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health