Provider Demographics
NPI:1871514778
Name:PHOENIX BEHAVIORAL HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:PHOENIX BEHAVIORAL HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:C
Authorized Official - Last Name:EIDEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:920-657-1780
Mailing Address - Street 1:3120 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-3229
Mailing Address - Country:US
Mailing Address - Phone:920-657-1780
Mailing Address - Fax:920-657-1784
Practice Address - Street 1:3120 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-3229
Practice Address - Country:US
Practice Address - Phone:920-657-1780
Practice Address - Fax:920-657-1784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42226300Medicaid