Organization
PHOENIX RECOVERY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
AMOND KENYUTTA TILLMAN LADC (SUBSTANCE ABUSE THERAPIST)
(203) 243-6170
Entity
Organization
Contact information
Practice address
4270 MAIN ST STE 200, BRIDGEPORT, CT 06606-2306
(203) 243-6170
Mailing address
14 MARIE DR APT 12, SEYMOUR, CT 06483-3665
(203) 243-6170
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
008087099
—
CT
Enumeration date
06/26/2019
Last updated
06/26/2019
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