Provider Demographics
NPI:1306305727
Name:RED PHOENIX HEALING LLC
Entity type:Organization
Organization Name:RED PHOENIX HEALING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEESKE
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:774-573-1644
Mailing Address - Street 1:89 MAIN ST STE 304
Mailing Address - Street 2:
Mailing Address - City:MEDWAY
Mailing Address - State:MA
Mailing Address - Zip Code:02053-1815
Mailing Address - Country:US
Mailing Address - Phone:774-573-1644
Mailing Address - Fax:774-233-0037
Practice Address - Street 1:89 MAIN ST STE 304
Practice Address - Street 2:
Practice Address - City:MEDWAY
Practice Address - State:MA
Practice Address - Zip Code:02053-1815
Practice Address - Country:US
Practice Address - Phone:774-573-1644
Practice Address - Fax:774-233-0037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-15
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health