Provider Demographics
NPI:1750774816
Name:PHASE LL ACADEMY, LLC
Entity type:Organization
Organization Name:PHASE LL ACADEMY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:FENNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-262-1811
Mailing Address - Street 1:PO BOX 1222
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-0222
Mailing Address - Country:US
Mailing Address - Phone:202-262-1811
Mailing Address - Fax:202-204-5807
Practice Address - Street 1:4702 14TH ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-4315
Practice Address - Country:US
Practice Address - Phone:202-545-0311
Practice Address - Fax:202-204-5807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC400313901068251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services