Healthcare Provider Details

I. General information

NPI: 1366649386
Provider Name (Legal Business Name): PHYLLIS WHITE PHELAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 ASBURY ST SUITE 302
SAINT PAUL MN
55104-1849
US

IV. Provider business mailing address

570 ASBURY ST SUITE 302
SAINT PAUL MN
55104-1849
US

V. Phone/Fax

Practice location:
  • Phone: 651-644-5275
  • Fax: 763-201-1095
Mailing address:
  • Phone: 651-644-5275
  • Fax: 763-201-1095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberLP1119
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: