Healthcare Provider Details

I. General information

NPI: 1386767994
Provider Name (Legal Business Name): PHOENIX PSYCHOLOGICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 S MERAMEC AVE SUITE 506
SAINT LOUIS MO
63105-3596
US

IV. Provider business mailing address

225 S MERAMEC AVE SUITE 506
SAINT LOUIS MO
63105-3596
US

V. Phone/Fax

Practice location:
  • Phone: 314-863-3588
  • Fax: 314-863-0074
Mailing address:
  • Phone: 314-863-3588
  • Fax: 314-863-0074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License NumberPY01201
License Number StateMO

VIII. Authorized Official

Name: DR. PATRICIA S SHAW
Title or Position: PRESIDENT
Credential: PHD
Phone: 314-863-3588