Healthcare Provider Details

I. General information

NPI: 1679358477
Provider Name (Legal Business Name): ROBERT PHILLIPS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2023
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4590 N QUAIL LAKE DR
CLOVIS CA
93619-4630
US

IV. Provider business mailing address

4590 N QUAIL LAKE DR
CLOVIS CA
93619-4630
US

V. Phone/Fax

Practice location:
  • Phone: 559-977-2649
  • Fax:
Mailing address:
  • Phone: 559-977-2649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMI2331
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: