MEDICARE: HEATHER ELIZABETH PHILLIPS LPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	167G00000X	Licensed Psychiatric Technician	41710	CA

General Provider Information

NPI Number	:	1114530250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER ELIZABETH PHILLIPS LPT

Provider Business Mailing Address
First Line	:	4900 N HIGHWAY 99 UNIT 68
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95212-1007
Country	:	US
Telephone Number	:	209-808-3284
Fax Number	:

Provider Business Practice Location Address
First Line	:	4900 N HIGHWAY 99 UNIT 68
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95212-1007
Country	:	US
Telephone Number	:	209-808-3284
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2020
Last Update Date	:	08/28/2020

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