Provider Demographics
NPI:1902309529
Name:PHILLIPS, TEZZA LYDIA (CADC-III)
Entity type:Individual
Prefix:MISS
First Name:TEZZA
Middle Name:LYDIA
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:CADC-III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8196 SW HALL BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-6401
Mailing Address - Country:US
Mailing Address - Phone:541-638-0830
Mailing Address - Fax:
Practice Address - Street 1:8196 SW HALL BLVD STE 230
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-6401
Practice Address - Country:US
Practice Address - Phone:541-638-0830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR8915101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA373781000Medicaid