Healthcare Provider Details

I. General information

NPI: 1316932833
Provider Name (Legal Business Name): PHOENIX GROUP MENTAL HEALTH SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 2ND AVE NE
CLARION IA
50525-1430
US

IV. Provider business mailing address

PO BOX 474
HUMBOLDT IA
50548-0474
US

V. Phone/Fax

Practice location:
  • Phone: 515-532-3338
  • Fax: 515-532-3339
Mailing address:
  • Phone: 515-532-3338
  • Fax: 515-532-3339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1316932833
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: MRS. SUSAN JEAN MARVIN
Title or Position: PRESIDENT
Credential: LISW
Phone: 515-532-3338