Provider Demographics
NPI:1114195914
Name:PHOENIX CENTER COMMUNITY SERVICE BOARD
Entity Type:Organization
Organization Name:PHOENIX CENTER COMMUNITY SERVICE BOARD
Other - Org Name:PHOENIX CENTER BHS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-988-1002
Mailing Address - Street 1:940 GA HIGHWAY 96
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-2584
Mailing Address - Country:US
Mailing Address - Phone:478-988-1002
Mailing Address - Fax:478-988-8780
Practice Address - Street 1:80 WRIGHT AVE
Practice Address - Street 2:
Practice Address - City:ROBERTA
Practice Address - State:GA
Practice Address - Zip Code:31078
Practice Address - Country:US
Practice Address - Phone:478-988-1002
Practice Address - Fax:478-988-8780
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX CENTER COMMUNITY SERVICE BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health