Provider Demographics
NPI:1316932833
Name:PHOENIX GROUP MENTAL HEALTH SERVICES INC
Entity type:Organization
Organization Name:PHOENIX GROUP MENTAL HEALTH SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:MARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:515-532-3338
Mailing Address - Street 1:PO BOX 474
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:IA
Mailing Address - Zip Code:50548-0474
Mailing Address - Country:US
Mailing Address - Phone:515-532-3338
Mailing Address - Fax:515-532-3339
Practice Address - Street 1:103 2ND AVE NE
Practice Address - Street 2:
Practice Address - City:CLARION
Practice Address - State:IA
Practice Address - Zip Code:50525-1430
Practice Address - Country:US
Practice Address - Phone:515-532-3338
Practice Address - Fax:515-532-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1316932833Medicaid
IAIB2243Medicare PIN
IAI20586Medicare PIN
IAI16957Medicare ID - Type Unspecified