Healthcare Provider Details

I. General information

NPI: 1447875133
Provider Name (Legal Business Name): PAUL D PHILLIP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2020
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 GOLF COURSE RD NE SUITE C
RIO RANCHO NM
87124
US

IV. Provider business mailing address

527 BRIANNA LOOP NE
ALBUQUERQUE NM
87113-1479
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-1229
  • Fax:
Mailing address:
  • Phone: 505-414-4029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: