Basic Information
| Provider Information | |||||||||
| NPI: | 1649424789 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHOENIX CENTER BEHAVIORAL HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 940 HIGHWAY 96 STE A | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310882587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789881222 | ||||||||
| FaxNumber: | 4789881422 | ||||||||
| Practice Location | |||||||||
| Address1: | 940 HIGHWAY 96 STE A | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310882587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789881222 | ||||||||
| FaxNumber: | 4789881422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | DEAN | ||||||||
| AuthorizedOfficialFirstName: | SHONTAON | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | LPN | ||||||||
| AuthorizedOfficialTelephone: | 4789881222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | GA | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 58215225 | 05 | GA | MEDICAID |