Provider Demographics
NPI:1588833271
Name:PHOENIX ADOLESCENT OUTPATIENT TREATMENT
Entity Type:Organization
Organization Name:PHOENIX ADOLESCENT OUTPATIENT TREATMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:MEIER
Authorized Official - Suffix:JR
Authorized Official - Credentials:LADC
Authorized Official - Phone:651-230-1895
Mailing Address - Street 1:1011 INTERLACHEN PKWY
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-8852
Mailing Address - Country:US
Mailing Address - Phone:651-230-0849
Mailing Address - Fax:651-773-5894
Practice Address - Street 1:2055 WHITE BEAR AVE N
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-3716
Practice Address - Country:US
Practice Address - Phone:651-734-3268
Practice Address - Fax:612-378-4886
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX GROUP HOMES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1048347-1-CDT251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health