Provider Demographics
NPI:1699164707
Name:BADGLEY, PHYLLIS
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:
Last Name:BADGLEY
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 1:3590 STATE ROUTE 59
Mailing Address - Street 2:SPECIAL SERVICES
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266
Mailing Address - Country:US
Mailing Address - Phone:330-297-6708
Mailing Address - Fax:330-297-7605
Practice Address - Street 1:3590 STATE ROUTE 59
Practice Address - Street 2:SPECIAL SERVICES
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266
Practice Address - Country:US
Practice Address - Phone:330-297-6708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool