Provider Demographics
NPI:1790117729
Name:CAMP PHOENIX
Entity Type:Organization
Organization Name:CAMP PHOENIX
Other - Org Name:PHOENIX CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EX. DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:ROSEN
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:830-613-7230
Mailing Address - Street 1:PO BOX 732
Mailing Address - Street 2:
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-0732
Mailing Address - Country:US
Mailing Address - Phone:830-613-7230
Mailing Address - Fax:
Practice Address - Street 1:3340 STATE HIGHWAY 71 W
Practice Address - Street 2:
Practice Address - City:HORSESHOE BAY
Practice Address - State:TX
Practice Address - Zip Code:78657-9657
Practice Address - Country:US
Practice Address - Phone:830-637-7848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-01
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX508751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX389257201Medicaid