Provider Demographics
NPI:1407917966
Name:PHOENIX ASSOCIATES INC.
Entity Type:Organization
Organization Name:PHOENIX ASSOCIATES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BLANKS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:260-424-0411
Mailing Address - Street 1:2200 LAKE AVE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5397
Mailing Address - Country:US
Mailing Address - Phone:260-424-0411
Mailing Address - Fax:260-424-3530
Practice Address - Street 1:2200 LAKE AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5397
Practice Address - Country:US
Practice Address - Phone:260-424-0411
Practice Address - Fax:260-424-3530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2022-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000785A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100080580AMedicaid
IN100080580AMedicaid