Provider Demographics
NPI:1699963207
Name:PHILLIPS, SANDRA L (M ED)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:L
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:M ED
Other - Prefix:MS
Other - First Name:SANDRA
Other - Middle Name:L
Other - Last Name:WEBSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:2624 9TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2350
Mailing Address - Country:US
Mailing Address - Phone:701-298-4500
Mailing Address - Fax:701-298-4400
Practice Address - Street 1:2624 9TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2350
Practice Address - Country:US
Practice Address - Phone:701-298-4500
Practice Address - Fax:701-298-4400
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ND1440101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND017919OtherBCBS OF ND PIN