Provider Demographics
NPI:1366649386
Name:PHELAN, PHYLLIS WHITE (PHD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:WHITE
Last Name:PHELAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 ASBURY ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1849
Mailing Address - Country:US
Mailing Address - Phone:651-644-5275
Mailing Address - Fax:763-201-1095
Practice Address - Street 1:570 ASBURY ST
Practice Address - Street 2:SUITE 302
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-1849
Practice Address - Country:US
Practice Address - Phone:651-644-5275
Practice Address - Fax:763-201-1095
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1119103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral