Provider Demographics
NPI:1497803001
Name:PHILLIPS, MICHAEL J (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 1ST PL NW
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-3271
Mailing Address - Country:US
Mailing Address - Phone:425-392-0277
Mailing Address - Fax:425-392-2509
Practice Address - Street 1:55 1ST PL NW
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-3271
Practice Address - Country:US
Practice Address - Phone:425-392-0277
Practice Address - Fax:425-392-2509
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001614103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPH3914OtherREGENCE PIN
4655971OtherAETNA US HEALTHCARE PIN