Provider Demographics
NPI:1831350982
Name:PHOENIX FAMILY SERVICES, LLC
Entity type:Organization
Organization Name:PHOENIX FAMILY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:KADIR
Authorized Official - Last Name:MAHARAJH
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:732-404-7604
Mailing Address - Street 1:210 RICHARDS AVE
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-2936
Mailing Address - Country:US
Mailing Address - Phone:732-404-7064
Mailing Address - Fax:732-424-6587
Practice Address - Street 1:210 RICHARDS AVE
Practice Address - Street 2:
Practice Address - City:PISCATAWAY
Practice Address - State:NJ
Practice Address - Zip Code:08854-2936
Practice Address - Country:US
Practice Address - Phone:732-404-7064
Practice Address - Fax:732-424-6587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-21
Last Update Date:2008-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ37PC00336800251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0162027Medicaid