Healthcare Provider Details

I. General information

NPI: 1902091622
Provider Name (Legal Business Name): PHOENIX GROUP-PSYCHIATRY AND PSYCHOTHERAPY SPECIALISTS, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9426 INDIAN SCHOOL RD NE #2
ALBUQUERQUE NM
87112
US

IV. Provider business mailing address

9426 INDIAN SCHOOL RD NE #2
ALBUQUERQUE NM
87112
US

V. Phone/Fax

Practice location:
  • Phone: 505-342-0400
  • Fax: 505-342-0500
Mailing address:
  • Phone: 505-342-0400
  • Fax: 505-342-0500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number798
License Number StateNM

VIII. Authorized Official

Name: SHERRY GRIBLING
Title or Position: SECRETARY OF CORP
Credential:
Phone: 505-342-0400