Healthcare Provider Details

I. General information

NPI: 1295018000
Provider Name (Legal Business Name): PHILLIP SQUIBB
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 PLUM HILL RD
KLAMATH FALLS OR
97601-9350
US

IV. Provider business mailing address

PO BOX 62
KLAMATH FALLS OR
97601-0004
US

V. Phone/Fax

Practice location:
  • Phone: 618-267-6121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6673
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: