=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932253465
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE PHOBIA CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2179 MIAMISBURG CENTERVILLE RD
-----------------------------------------------------
City | CENTERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45459-3814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-435-0998
-----------------------------------------------------
Fax | 937-435-7322
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2179 MIAMISBURG CENTERVILLE RD
-----------------------------------------------------
City | CENTERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45459-3814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-435-0998
-----------------------------------------------------
Fax | 937-435-7322
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OWNER
-----------------------------------------------------
Name | JOSE A COLLARES
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 937-435-0998
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 5738
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 6234
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 35046922
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------