MEDICARE: PHOENIX GROUP MENTAL HEALTH SERVICES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316932833
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX GROUP MENTAL HEALTH SERVICES INC

Provider Business Mailing Address
First Line	:	PO BOX 474
Second Line	:
City	:	HUMBOLDT
State	:	IA
Zip	:	50548-0474
Country	:	US
Telephone Number	:	515-532-3338
Fax Number	:	515-532-3339

Provider Business Practice Location Address
First Line	:	103 2ND AVE NE
Second Line	:
City	:	CLARION
State	:	IA
Zip	:	50525-1430
Country	:	US
Telephone Number	:	515-532-3338
Fax Number	:	515-532-3339

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. SUSAN JEAN MARVIN
Credential	:	LISW
Telephone Number	:	515-532-3338

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	06/25/2015

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