Healthcare Provider Details

I. General information

NPI: 1477429439
Provider Name (Legal Business Name): PHOENIX COLLECTIVE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 10/15/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7456 MISSION GORGE ROAD UNIT 165
SAN DIEGO CA
92120-1301
US

IV. Provider business mailing address

344 N CENTRAL AVE APT 9
MEDFORD OR
97501-5952
US

V. Phone/Fax

Practice location:
  • Phone: 619-535-0773
  • Fax: 619-535-7055
Mailing address:
  • Phone: 619-535-0773
  • Fax: 619-535-7055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. ROBIN MATHY
Title or Position: PRESIDENT AND CEO
Credential: MSW, MSC, LCSW
Phone: 651-535-0773