Healthcare Provider Details

I. General information

NPI: 1265479562
Provider Name (Legal Business Name): YVETTE MICHELLE PHILLIPS PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 05/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6612 N RIVERSIDE DR UNIT 140
FORT WORTH TX
76137-6664
US

IV. Provider business mailing address

6612 N RIVERSIDE DR UNIT 140
FORT WORTH TX
76137-6664
US

V. Phone/Fax

Practice location:
  • Phone: 817-306-9770
  • Fax: 817-306-9770
Mailing address:
  • Phone: 817-306-9770
  • Fax: 817-306-9770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number63253
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number002675
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: