=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730917964
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA BONNIE PHILLIPS PSY.D., HSPP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2024
-----------------------------------------------------
Last Update Date | 07/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 716 SEBERGER DR
-----------------------------------------------------
City | MUNSTER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46321-1628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-588-7391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 632 QUAIL DR
-----------------------------------------------------
City | HOBART
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46342-2370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------