Provider Demographics
NPI:1639399074
Name:UPHAM, PHILLIP V
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:UPHAM
Suffix:V
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 W MAIN ST,
Mailing Address - Street 2:SUITE 210-2422
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2570
Mailing Address - Country:US
Mailing Address - Phone:505-832-5918
Mailing Address - Fax:505-832-5918
Practice Address - Street 1:2040 W MAIN ST
Practice Address - Street 2:STE 210-2422
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-0904
Practice Address - Country:US
Practice Address - Phone:505-832-5817
Practice Address - Fax:505-832-5918
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-1756104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker