Provider Demographics
| NPI: | 1740065713 |
|---|---|
| Name: | PHOENIX PLACE |
| Entity type: | Organization |
| Organization Name: | PHOENIX PLACE |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | EXECUTIVE DIRECTOR |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | DIAMOND |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | CALLOWAY |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 502-656-9261 |
| Mailing Address - Street 1: | 2012 W CHESTNUT ST |
| Mailing Address - Street 2: | |
| Mailing Address - City: | LOUISVILLE |
| Mailing Address - State: | KY |
| Mailing Address - Zip Code: | 40203-1542 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 502-656-9261 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 2012 W CHESTNUT ST |
| Practice Address - Street 2: | |
| Practice Address - City: | LOUISVILLE |
| Practice Address - State: | KY |
| Practice Address - Zip Code: | 40203-1542 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 502-656-9261 |
| Practice Address - Fax: | |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2023-08-29 |
| Last Update Date: | 2024-05-07 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 251S00000X | Agencies | Community/Behavioral Health | Group - Multi-Specialty | |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
| No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | |
| No | 3245S0500X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | |
| No | 251B00000X | Agencies | Case Management | ||
| No | 276400000X | Hospital Units | Rehabilitation, Substance Use Disorder Unit | Group - Multi-Specialty | |
| No | 320800000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | ||
| No | 320900000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities | ||
| No | 343900000X | Transportation Services | Non-emergency Medical Transport (VAN) |
