Healthcare Provider Details

I. General information

NPI: 1609088798
Provider Name (Legal Business Name): PHOENIX HOMES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 N MAIN ST
DELPHOS OH
45891
US

IV. Provider business mailing address

233 N MAIN ST
DELPHOS OH
45891
US

V. Phone/Fax

Practice location:
  • Phone: 419-692-2421
  • Fax: 419-692-2300
Mailing address:
  • Phone: 419-692-2421
  • Fax: 419-692-2300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number40064
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number00294
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number500544
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number496
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberSO10124A
License Number StateTN
# 6
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberSO10103A
License Number StateTN
# 7
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberSO10102A
License Number StateTN
# 8
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number046478
License Number StateAL

VIII. Authorized Official

Name: BRUCE MAAG
Title or Position: CEO
Credential: MS., LPC, LSW
Phone: 419-692-2421