Provider Demographics
NPI:1215146246
Name:PHILLIPS, SUSAN PATRICIA (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:PATRICIA
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:PATRICIA
Other - Last Name:COCHRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:2824 WINDGUARD CIR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-7369
Mailing Address - Country:US
Mailing Address - Phone:813-997-4538
Mailing Address - Fax:813-991-7584
Practice Address - Street 1:17742 NATHANS DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2264
Practice Address - Country:US
Practice Address - Phone:205-792-4477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7291103TC1900X
AL757103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL51074669COCMedicare UPIN
ALR63059Medicare ID - Type Unspecified