Provider Demographics
NPI:1104079474
Name:FAITH L. PHILLIPS, PH.D., PLLC
Entity type:Organization
Organization Name:FAITH L. PHILLIPS, PH.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:L
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:580-584-5550
Mailing Address - Street 1:411 S. PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-3331
Mailing Address - Country:US
Mailing Address - Phone:580-584-5550
Mailing Address - Fax:866-584-1223
Practice Address - Street 1:411 S. PARK DRIVE
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-3331
Practice Address - Country:US
Practice Address - Phone:580-584-5550
Practice Address - Fax:866-584-1223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-29
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK513103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200216630AMedicaid