Provider Demographics
NPI:1336333079
Name:PHOENIX THERAPEUTIC FOUNDATION
Entity type:Organization
Organization Name:PHOENIX THERAPEUTIC FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:AMR
Authorized Official - Middle Name:A
Authorized Official - Last Name:EL-BESHIR
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:410-744-9100
Mailing Address - Street 1:5602 BALTIMORE NATIONAL PIKE
Mailing Address - Street 2:SUITE 700
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-1411
Mailing Address - Country:US
Mailing Address - Phone:410-744-9100
Mailing Address - Fax:410-747-0226
Practice Address - Street 1:5602 BALTIMORE NATIONAL PIKE
Practice Address - Street 2:SUBURBIA BLDG - SUITE # 508/6
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-1411
Practice Address - Country:US
Practice Address - Phone:410-744-9100
Practice Address - Fax:410-747-0226
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX THERAPEUTIC FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-05
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0016432251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD401254200Medicaid