Provider Demographics
NPI:1164571014
Name:FIEDLER, PHYLLIS (PHD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:FIEDLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:DECKY
Other - Middle Name:
Other - Last Name:FIEDLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:2448 76TH AVE SE
Mailing Address - Street 2:STE 207
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-2744
Mailing Address - Country:US
Mailing Address - Phone:206-439-1762
Mailing Address - Fax:
Practice Address - Street 1:8015 SE 28TH ST
Practice Address - Street 2:#201
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-2910
Practice Address - Country:US
Practice Address - Phone:206-439-1762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2016-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA583103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB21274Medicare ID - Type Unspecified