Provider Demographics
NPI:1689144834
Name:PHOENIX COUNSELING & MEDIATION SERVICES LLC
Entity Type:Organization
Organization Name:PHOENIX COUNSELING & MEDIATION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PENELOPE
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPCC-S
Authorized Official - Phone:740-619-0363
Mailing Address - Street 1:670A E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43713-1455
Mailing Address - Country:US
Mailing Address - Phone:740-619-0363
Mailing Address - Fax:740-619-0347
Practice Address - Street 1:670A E MAIN ST
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43713-1455
Practice Address - Country:US
Practice Address - Phone:740-619-0363
Practice Address - Fax:740-619-0347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0083745Medicaid