| Phoenix Associates Inc. | |
|
2200 Lake Ave Suite 260 Fort Wayne IN 46805-5397 | |
| (260) 424-0411 | |
| (260) 424-3530 |
| Full Name | Phoenix Associates Inc. |
|---|---|
| Speciality | Social Worker |
| Location | 2200 Lake Ave, Fort Wayne, Indiana |
| Authorized Official Name and Position | John William Blanks (PRESIDENT) |
| Authorized Official Contact | 2604240411 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Phoenix Associates Inc. 2200 Lake Ave Suite 260 Fort Wayne IN 46805-5397 Ph: (260) 424-0411 | Phoenix Associates Inc. 2200 Lake Ave Suite 260 Fort Wayne IN 46805-5397 Ph: (260) 424-0411 |
| NPI Number | 1407917966 |
|---|---|
| Provider Enumeration Date | 12/12/2006 |
| Last Update Date | 04/02/2022 |
| Certification Date | 04/02/2022 |
| Medicare PECOS PAC ID | 9931179603 |
|---|---|
| Medicare Enrollment ID | O20040729000644 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1407917966 | NPI | - | NPPES |
| 100080580A | Medicaid | IN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | 34000785A (Indiana) | Primary |
| Provider Name | Mary H Rose |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1891856399 PECOS PAC ID: 2961473863 Enrollment ID: I20040804000593 |
| Provider Name | Gregory M. Banicki |
|---|---|
| Provider Type | Practitioner - Marriage And Family Therapist |
| Provider Identifiers | NPI Number: 1184785693 PECOS PAC ID: 2961939947 Enrollment ID: I20250103000101 |
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