Provider Demographics
NPI:1174679732
Name:PHILLIPS, MOLLIE ADELL (QHMA)
Entity Type:Individual
Prefix:MISS
First Name:MOLLIE
Middle Name:ADELL
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:QHMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5524 SE 115TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-3902
Mailing Address - Country:US
Mailing Address - Phone:503-761-4790
Mailing Address - Fax:
Practice Address - Street 1:5524 SE 115TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-3902
Practice Address - Country:US
Practice Address - Phone:503-761-4790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator