Provider Demographics
NPI:1407922099
Name:PHOENIX, JUDY K (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDY
Middle Name:K
Last Name:PHOENIX
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:PO BOX 82
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89504-0082
Mailing Address - Country:US
Mailing Address - Phone:775-322-5055
Mailing Address - Fax:775-322-5055
Practice Address - Street 1:216 MOUNT ROSE ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-3352
Practice Address - Country:US
Practice Address - Phone:775-322-5055
Practice Address - Fax:775-322-5055
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPSY0123103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPHD123Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER