Provider Demographics
NPI:1861053183
Name:PHOENIX RECOVERY, LLC
Entity type:Organization
Organization Name:PHOENIX RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUBSTANCE ABUSE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AMOND
Authorized Official - Middle Name:KENYUTTA
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:203-243-6170
Mailing Address - Street 1:14 MARIE DR APT 12
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:CT
Mailing Address - Zip Code:06483-3665
Mailing Address - Country:US
Mailing Address - Phone:203-243-6170
Mailing Address - Fax:
Practice Address - Street 1:4270 MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-2306
Practice Address - Country:US
Practice Address - Phone:203-243-6170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008087099Medicaid