Provider Demographics
NPI:1316319510
Name:PHILLIPS, ANGELA LACYNDA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:LACYNDA
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 589
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:OK
Mailing Address - Zip Code:74873-0589
Mailing Address - Country:US
Mailing Address - Phone:405-585-3833
Mailing Address - Fax:
Practice Address - Street 1:602 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:OK
Practice Address - Zip Code:74873-2020
Practice Address - Country:US
Practice Address - Phone:405-585-3833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6747101Y00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1316319510OtherINDIVIDUAL NPI
OK134602OtherEAST CENTRAL UNIVERSITY
OK6747OtherLPC LICENSED