Healthcare Provider Details

I. General information

NPI: 1932136108
Provider Name (Legal Business Name): THERESA PHILLIPS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E RICHMOND AVE
RICHMOND CA
94801-4034
US

IV. Provider business mailing address

1 BAYWOOD AVE SUITE 7
SAN MATEO CA
94402-1537
US

V. Phone/Fax

Practice location:
  • Phone: 510-237-6865
  • Fax:
Mailing address:
  • Phone: 650-344-6961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY 19723
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: