Provider Demographics
NPI:1437590601
Name:PHOENIX MENTAL HEALTH LLC
Entity Type:Organization
Organization Name:PHOENIX MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:MASON
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD, LPC, ACS
Authorized Official - Phone:757-453-4017
Mailing Address - Street 1:810 KEMPSVILLE RD STE 6
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-2723
Mailing Address - Country:US
Mailing Address - Phone:757-453-4017
Mailing Address - Fax:
Practice Address - Street 1:100 S BOGGS AVE
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1705
Practice Address - Country:US
Practice Address - Phone:757-453-4017
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-16
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003229305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1891042438OtherNPI