Provider Demographics
NPI:1285193979
Name:PHOENIX RECOVERY HOUSE
Entity type:Organization
Organization Name:PHOENIX RECOVERY HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR III
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:CDP, LICSW
Authorized Official - Phone:360-848-8437
Mailing Address - Street 1:7440 W MARGINAL WAY S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98108-4141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 E COLLEGE WAY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5612
Practice Address - Country:US
Practice Address - Phone:360-848-8437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PIONEER HUMAN SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health