Provider Demographics
NPI:1184859274
Name:PHOENIX ASSOCIATES OF HANCOCK COUNTY, LLC
Entity Type:Organization
Organization Name:PHOENIX ASSOCIATES OF HANCOCK COUNTY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:KEISTER
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC, CADACII
Authorized Official - Phone:317-462-8281
Mailing Address - Street 1:415 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-2056
Mailing Address - Country:US
Mailing Address - Phone:317-462-8281
Mailing Address - Fax:317-462-8289
Practice Address - Street 1:415 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-2056
Practice Address - Country:US
Practice Address - Phone:317-462-8281
Practice Address - Fax:317-462-8289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1592-0-ASO251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health