Healthcare Provider Details

I. General information

NPI: 1710422613
Provider Name (Legal Business Name): PHYLLIS KHAO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2016
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date: 02/19/2019
Reactivation Date: 02/27/2019

III. Provider practice location address

13400 E. SHEA BLVD.
SCOTTSDALE AZ
85259
US

IV. Provider business mailing address

13400 E. SHEA BLVD.
SCOTTSDALE AZ
85259
US

V. Phone/Fax

Practice location:
  • Phone: 480-301-8000
  • Fax: 860-253-5030
Mailing address:
  • Phone: 480-301-8000
  • Fax: 860-731-5536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number7458
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: