Healthcare Provider Details

I. General information

NPI: 1093366775
Provider Name (Legal Business Name): PHOENIX BEHAVIORAL HEALTH CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 BIENVILLE BLVD STE K
OCEAN SPRINGS MS
39564-3067
US

IV. Provider business mailing address

2112 BIENVILLE BLVD STE K
OCEAN SPRINGS MS
39564-3067
US

V. Phone/Fax

Practice location:
  • Phone: 228-819-2171
  • Fax: 228-205-4986
Mailing address:
  • Phone: 228-819-2171
  • Fax: 833-779-1879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. KATHRYN KIM WAGGONER
Title or Position: CEO
Credential: PSYD, ABPP
Phone: 228-819-2171