Provider Demographics
NPI:1639227028
Name:PHOENIX GATE INC
Entity Type:Organization
Organization Name:PHOENIX GATE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:PROF
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:ECKENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LADC, CCS
Authorized Official - Phone:580-364-0700
Mailing Address - Street 1:211 E COURT ST STE 6
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-2000
Mailing Address - Country:US
Mailing Address - Phone:580-364-0700
Mailing Address - Fax:580-364-0701
Practice Address - Street 1:211 E COURT ST STE 6
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-2000
Practice Address - Country:US
Practice Address - Phone:580-364-0700
Practice Address - Fax:580-364-0701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty