Healthcare Provider Details

I. General information

NPI: 1316425416
Provider Name (Legal Business Name): CHRISTINE HAZARD PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6020 CONSTITUTION AVE NE STE 4
ALBUQUERQUE NM
87110-5931
US

IV. Provider business mailing address

PO BOX 3338
ALBUQUERQUE NM
87190-3338
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-5099
  • Fax: 505-255-4206
Mailing address:
  • Phone: 505-255-5099
  • Fax: 505-255-5099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1360
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: