Provider Demographics
NPI:1649424789
Name:PHOENIX CENTER BEHAVIORAL HEALTH SERVICES
Entity type:Organization
Organization Name:PHOENIX CENTER BEHAVIORAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:SHONTAON
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-988-1222
Mailing Address - Street 1:940 HIGHWAY 96 STE A
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-2587
Mailing Address - Country:US
Mailing Address - Phone:478-988-1222
Mailing Address - Fax:478-988-1422
Practice Address - Street 1:940 HIGHWAY 96 STE A
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-2587
Practice Address - Country:US
Practice Address - Phone:478-988-1222
Practice Address - Fax:478-988-1422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA58215225Medicaid