Provider Demographics
NPI:1831435379
Name:PHOENIX WELLNESS GROUP, LLC
Entity type:Organization
Organization Name:PHOENIX WELLNESS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:K
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:270-943-1851
Mailing Address - Street 1:2702 INDUSTRIAL DR APT 610
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-4154
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1030 SHIVE LN
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-8037
Practice Address - Country:US
Practice Address - Phone:270-943-1851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-02
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)