Provider Demographics
NPI:1780280354
Name:UNLEASHED PHOENIX CORP
Entity type:Organization
Organization Name:UNLEASHED PHOENIX CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-216-1237
Mailing Address - Street 1:2538 E UNIVERSITY DR STE 165
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85034-6905
Mailing Address - Country:US
Mailing Address - Phone:623-282-4254
Mailing Address - Fax:
Practice Address - Street 1:2538 E UNIVERSITY DR STE 165
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-6905
Practice Address - Country:US
Practice Address - Phone:232-824-2546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-09
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health