Provider Demographics
NPI:1386767994
Name:PHOENIX PSYCHOLOGICAL GROUP, INC
Entity type:Organization
Organization Name:PHOENIX PSYCHOLOGICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:314-863-3588
Mailing Address - Street 1:225 S MERAMEC AVE
Mailing Address - Street 2:SUITE 506
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-3596
Mailing Address - Country:US
Mailing Address - Phone:314-863-3588
Mailing Address - Fax:314-863-0074
Practice Address - Street 1:225 S MERAMEC AVE
Practice Address - Street 2:SUITE 506
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-3596
Practice Address - Country:US
Practice Address - Phone:314-863-3588
Practice Address - Fax:314-863-0074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY01201103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493257802Medicaid
MO1245254317OtherNPI-PATRICIA SHAW
MO00754Medicare UPIN