# PHOENIX BRIDGE COMMUNITY SUPPORT

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Parent organization:** PHOENIX BRIDGE GROUP HOME, INC.
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1508045998
- **Legal business name:** PHOENIX BRIDGE GROUP HOME, INC.
- **Authorized official:** MISS WENDY RENEE JONES (PROGRAM DIRECTOR)
- **Authorized official phone:** (336) 222-8522

## Contact information

- **Practice address:** 814 BRADLEY ST, BURLINGTON, NC 27215-6806
- **Practice address phone:** (336) 222-8522
- **Practice address fax:** (336) 222-8533
- **Mailing address:** 909 A SOUTH MAIN STREET, BURLINGTON, NC 27215-5756
- **Mailing address phone:** (336) 222-8522
- **Mailing address fax:** (336) 222-8533

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 322D00000X | Emotionally Disturbed Childrens' Residential Treatment Facility | MHL-001-121 | NC | Yes |

## Other

- **Enumeration date:** 11/01/2007
- **Last updated:** 11/01/2007

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 6603578 | — | NC |