Provider Demographics
NPI:1982760625
Name:PHOENIX, SHAUN L (LCPC)
Entity Type:Individual
Prefix:MS
First Name:SHAUN
Middle Name:L
Last Name:PHOENIX
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 LITTLE BROOK LN
Mailing Address - Street 2:
Mailing Address - City:BELGRADE
Mailing Address - State:MT
Mailing Address - Zip Code:59714-9533
Mailing Address - Country:US
Mailing Address - Phone:406-580-0562
Mailing Address - Fax:
Practice Address - Street 1:17 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-4443
Practice Address - Country:US
Practice Address - Phone:406-580-0562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT914101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000252518Medicaid
MT1982760625Medicaid