Provider Demographics
NPI:1609088798
Name:PHOENIX HOMES, INC
Entity Type:Organization
Organization Name:PHOENIX HOMES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAAG
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC, LSW
Authorized Official - Phone:419-692-2421
Mailing Address - Street 1:233 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45891
Mailing Address - Country:US
Mailing Address - Phone:419-692-2421
Mailing Address - Fax:419-692-2300
Practice Address - Street 1:233 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DELPHOS
Practice Address - State:OH
Practice Address - Zip Code:45891
Practice Address - Country:US
Practice Address - Phone:419-692-2421
Practice Address - Fax:419-692-2300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI40064251S00000X
MD00294251S00000X
KY500544251S00000X
OH496251S00000X
TNSO10124A251S00000X
TNSO10103A251S00000X
TNSO10102A251S00000X
AL046478322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL322D0000XMedicaid