Healthcare Provider Details

I. General information

NPI: 1871302919
Provider Name (Legal Business Name): PHOENIX BULLIS-CABALLOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2025
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 NIKKI VIEW DR
BRANDON FL
33511-4868
US

IV. Provider business mailing address

10914 LE JARDIN CIR APT 102
TEMPLE TERRACE FL
33617-2810
US

V. Phone/Fax

Practice location:
  • Phone: 813-680-1367
  • Fax:
Mailing address:
  • Phone: 813-593-7053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW26301
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: