MEDICARE: GOLDEN PHOENIX MENTAL HEALTH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861080319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN PHOENIX MENTAL HEALTH LLC

Provider Business Mailing Address
First Line	:	2328 HANCOCK BRIDGE PKWY STE 109
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-1455
Country	:	US
Telephone Number	:	786-353-2324
Fax Number	:	786-957-2909

Provider Business Practice Location Address
First Line	:	2328 HANCOCK BRIDGE PKWY STE 109
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-1455
Country	:	US
Telephone Number	:	786-353-2324
Fax Number	:	786-957-2909

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	INGRID CRUZ UGUET
Credential	:	CBHCMS
Telephone Number	:	786-353-2324

Provider Enumeration Date	:	01/08/2021
Last Update Date	:	06/19/2026

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