Organization
PHOENIX DOMUS
Active
Organization
PHOENIX DOMUS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. GREGORY ALAN MCCONNELL B.S., M.ED., CHES (PROGRAM MANAGER)
(814) 934-6513
Entity
Organization
Contact information
Practice address
114 BEECH AVE, ALTOONA, PA 16601-4235
(814) 502-5157
Mailing address
114 BEECH AVE, ALTOONA, PA 16601-4235
(814) 502-5157
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
251S00000X
Community/Behavioral Health Agency
—
—
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
—
—
324500000X
Substance Abuse Rehabilitation Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
077037
—
PA
Enumeration date
04/05/2021
Last updated
06/24/2026
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