Provider Demographics
NPI:1588917520
Name:PHOENIX PSYCHOLOGICAL GROUP, PC
Entity type:Organization
Organization Name:PHOENIX PSYCHOLOGICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:BARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:805-637-9997
Mailing Address - Street 1:35 W MAIN ST
Mailing Address - Street 2:SUITE B-368
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-2507
Mailing Address - Country:US
Mailing Address - Phone:805-232-4148
Mailing Address - Fax:
Practice Address - Street 1:1601 CARMEN DR
Practice Address - Street 2:SUITE 211
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-3105
Practice Address - Country:US
Practice Address - Phone:805-232-4148
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-15
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21349103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty