Provider Demographics
NPI:1497434930
Name:PHILLIPS, SADE
Entity Type:Individual
Prefix:
First Name:SADE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LOLA
Other - Middle Name:
Other - Last Name:SADE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8721 OWENSMOUTH AVE APT 210
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-2417
Mailing Address - Country:US
Mailing Address - Phone:818-854-9766
Mailing Address - Fax:
Practice Address - Street 1:8721 OWENSMOUTH AVE APT 210
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91304-2417
Practice Address - Country:US
Practice Address - Phone:818-854-9766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86268225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty