Provider Demographics
NPI:1417221128
Name:WASHINGTON, PHYLLIS
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22103 VISTA DEL PLAZA LN APT 19
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-2860
Mailing Address - Country:US
Mailing Address - Phone:510-517-2772
Mailing Address - Fax:
Practice Address - Street 1:426 17TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2820
Practice Address - Country:US
Practice Address - Phone:510-517-2772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-27
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
CA152082106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator