Provider Demographics
NPI:1306314349
Name:PHILLIPS, TERA JOYCE (CDP)
Entity type:Individual
Prefix:
First Name:TERA
Middle Name:JOYCE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 S SOLMAR DR
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-7522
Mailing Address - Country:US
Mailing Address - Phone:360-406-0794
Mailing Address - Fax:
Practice Address - Street 1:112 S SOLMAR DR
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382
Practice Address - Country:US
Practice Address - Phone:360-406-0794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60783252101Y00000X
WACP60185869101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor