Provider Demographics
NPI:1366124778
Name:THE PHOENIX REBORN LLC
Entity type:Organization
Organization Name:THE PHOENIX REBORN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:HAVA
Authorized Official - Middle Name:LEAH
Authorized Official - Last Name:JAROSZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-840-8236
Mailing Address - Street 1:18 PARKWIND CT
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-4237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 PARKWIND CT
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MD
Practice Address - Zip Code:21234-4237
Practice Address - Country:US
Practice Address - Phone:443-840-8236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-04
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty