Organization
PHOENIX HOUSE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ELLEN M WALTMAN MED,LMHC (CLINICAL SUPERVISOR)
(413) 355-6832
Entity
Organization
Contact information
Practice address
5 MADISON AVE, SPRINGFIELD, MA 01105-1403
(413) 733-6051
Mailing address
5 MADISON AVENUE, SPRINGFIELD, MA 01105
(413) 733-6051
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
745
MA
302F00000X
Exclusive Provider Organization
745
MA
324500000X
Substance Abuse Rehabilitation Facility
Primary
745
MA
Other
Enumeration date
01/26/2015
Last updated
01/26/2015
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