Provider Demographics
NPI:1205846433
Name:MASSAD, PHILLIP MICHAEL (PHD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:MICHAEL
Last Name:MASSAD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 NW 38TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-8412
Mailing Address - Country:US
Mailing Address - Phone:405-528-1487
Mailing Address - Fax:405-521-0019
Practice Address - Street 1:416 NW 38TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-8412
Practice Address - Country:US
Practice Address - Phone:405-528-1487
Practice Address - Fax:405-521-0019
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1005103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical