Provider Demographics
NPI:1215608146
Name:PHOENIX HOLISTIC SERVICES LLC
Entity type:Organization
Organization Name:PHOENIX HOLISTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMART
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:917-226-6726
Mailing Address - Street 1:15569 115TH RD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-1023
Mailing Address - Country:US
Mailing Address - Phone:917-226-6726
Mailing Address - Fax:
Practice Address - Street 1:15569 115TH RD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-1023
Practice Address - Country:US
Practice Address - Phone:917-226-6726
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty