Healthcare Provider Details

I. General information

NPI: 1134530199
Provider Name (Legal Business Name): SALLY PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 MARSCHALL RD SUITE 250
SHAKOPEE MN
55379-1687
US

IV. Provider business mailing address

2497 7TH AVE E SUITE 101
NORTH ST PAUL MN
55109-2902
US

V. Phone/Fax

Practice location:
  • Phone: 651-769-6500
  • Fax: 651-769-6549
Mailing address:
  • Phone: 651-769-6437
  • Fax: 651-769-6449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5503
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: