Provider Demographics
NPI:1902091622
Name:PHOENIX GROUP-PSYCHIATRY AND PSYCHOTHERAPY SPECIALISTS, LTD
Entity type:Organization
Organization Name:PHOENIX GROUP-PSYCHIATRY AND PSYCHOTHERAPY SPECIALISTS, LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY OF CORP
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIBLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-342-0400
Mailing Address - Street 1:9426 INDIAN SCHOOL RD NE
Mailing Address - Street 2:#2
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112
Mailing Address - Country:US
Mailing Address - Phone:505-342-0400
Mailing Address - Fax:505-342-0500
Practice Address - Street 1:9426 INDIAN SCHOOL RD NE
Practice Address - Street 2:#2
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112
Practice Address - Country:US
Practice Address - Phone:505-342-0400
Practice Address - Fax:505-342-0500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM798103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM585508121Medicare PIN