Provider Demographics
NPI:1962733758
Name:PHOENIX GATE, INC.
Entity type:Organization
Organization Name:PHOENIX GATE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:IVORA
Authorized Official - Middle Name:P
Authorized Official - Last Name:SENSIBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:918-423-9400
Mailing Address - Street 1:32 E CHEROKEE AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-5323
Mailing Address - Country:US
Mailing Address - Phone:918-423-9400
Mailing Address - Fax:918-423-9400
Practice Address - Street 1:32 E CHEROKEE AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5323
Practice Address - Country:US
Practice Address - Phone:918-423-9400
Practice Address - Fax:918-423-9400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)