| Phoenix Behavioral Health Center, Pllc | |
|
2112 Bienville Blvd Ste K Ocean Springs MS 39564-3067 | |
| (228) 819-2171 | |
| (228) 205-4986 |
| Full Name | Phoenix Behavioral Health Center, Pllc |
|---|---|
| Speciality | Psychologist |
| Location | 2112 Bienville Blvd Ste K, Ocean Springs, Mississippi |
| Authorized Official Name and Position | Kathryn Kim Waggoner (CEO) |
| Authorized Official Contact | 2288192171 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Phoenix Behavioral Health Center, Pllc 2112 Bienville Blvd Ste K Ocean Springs MS 39564-3067 Ph: (228) 819-2171 | Phoenix Behavioral Health Center, Pllc 2112 Bienville Blvd Ste K Ocean Springs MS 39564-3067 Ph: (228) 819-2171 |
| NPI Number | 1093366775 |
|---|---|
| Provider Enumeration Date | 09/24/2019 |
| Last Update Date | 06/10/2024 |
| Certification Date | 06/10/2024 |
| Medicare PECOS PAC ID | 6204261985 |
|---|---|
| Medicare Enrollment ID | O20200128000498 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1093366775 | NPI | - | NPPES |
| Provider Name | Kathryn Kim Waggoner |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1316188121 PECOS PAC ID: 7911237540 Enrollment ID: I20190925001487 |
| Provider Name | Amy E Wilkinson |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1235256306 PECOS PAC ID: 6204287444 Enrollment ID: I20240111003530 |
| Provider Name | Suzanne Marie Ganschow |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1073547238 PECOS PAC ID: 3971839838 Enrollment ID: I20240112000923 |
| Provider Name | Dewey Watkins |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1356443121 PECOS PAC ID: 4284019274 Enrollment ID: I20240205001525 |
| Provider Name | Shelby Lynn Reeves |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1275309973 PECOS PAC ID: 6305282922 Enrollment ID: I20240306000847 |
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