Provider Demographics
NPI:1699925867
Name:PHILLIPS, FAITH LUCILLE (PHD)
Entity type:Individual
Prefix:DR
First Name:FAITH
Middle Name:LUCILLE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 S. PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-3331
Mailing Address - Country:US
Mailing Address - Phone:580-584-5550
Mailing Address - Fax:866-584-1223
Practice Address - Street 1:411 S. PARK DRIVE
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728
Practice Address - Country:US
Practice Address - Phone:580-584-5550
Practice Address - Fax:866-584-1223
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-24
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK513103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100837660AMedicaid