Provider Demographics
NPI:1174828107
Name:PHILLIPS, CORI VALDENE
Entity Type:Individual
Prefix:MR
First Name:CORI
Middle Name:VALDENE
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 E 73RD ST APT 702
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-7410
Mailing Address - Country:US
Mailing Address - Phone:404-895-6122
Mailing Address - Fax:
Practice Address - Street 1:1704 E 73RD ST APT 702
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-7410
Practice Address - Country:US
Practice Address - Phone:404-895-6122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-23
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UNDER SUPERVISION101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200385110Medicaid