Healthcare Provider Details

I. General information

NPI: 1811609464
Provider Name (Legal Business Name): PHILIPS EFE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2022
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 TANNER WAY
GRAND PRAIRIE TX
75052-4239
US

IV. Provider business mailing address

2821 TANNER WAY
GRAND PRAIRIE TX
75052-4239
US

V. Phone/Fax

Practice location:
  • Phone: 682-203-4090
  • Fax:
Mailing address:
  • Phone: 682-203-4090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number84304
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: