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General NPI Number Information
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NPI Number | 1639227028
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Entity Type | Organization
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Legal Business Name | PHOENIX GATE INC
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Dates
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Enumeration Date | 01/08/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 211 E COURT ST STE 6
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City | ATOKA
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State | OK
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Zip | 74525-2000
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Country | US
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Telephone | 580-364-0700
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Fax | 580-364-0701
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Provider Business Mailing Address
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Address Line | 211 E COURT ST STE 6
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City | ATOKA
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State | OK
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Zip | 74525-2000
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Country | US
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Telephone | 580-364-0700
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Fax | 580-364-0701
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | PROF. JOHN E ECKENBERGER
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Credential | LCSW, LADC, CCS
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Telephone | 580-364-0700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 256
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License Number State | OK
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