Provider Demographics
NPI:1619237377
Name:PHELPS, JUSTIN SCOTT (EDD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:SCOTT
Last Name:PHELPS
Suffix:
Gender:M
Credentials:EDD
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 353
Mailing Address - Street 2:
Mailing Address - City:CENTRAL
Mailing Address - State:AZ
Mailing Address - Zip Code:85531-0353
Mailing Address - Country:US
Mailing Address - Phone:928-551-1396
Mailing Address - Fax:
Practice Address - Street 1:5 SAN CARLOS BLVD.
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:AZ
Practice Address - Zip Code:85550
Practice Address - Country:US
Practice Address - Phone:928-475-4875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3658103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool