Provider Demographics
NPI:1043363153
Name:BAINES, PHYLLIS ANN (MA, IMF)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:ANN
Last Name:BAINES
Suffix:
Gender:F
Credentials:MA, IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N TEXAS ST STE A
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-1639
Mailing Address - Country:US
Mailing Address - Phone:707-428-4198
Mailing Address - Fax:707-423-2020
Practice Address - Street 1:2500 N TEXAS ST STE A
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-1639
Practice Address - Country:US
Practice Address - Phone:707-428-4198
Practice Address - Fax:707-423-2020
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 47731101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health