Provider Demographics
NPI:1659852101
Name:PHELPS, TORI ALEXANDRA
Entity Type:Individual
Prefix:
First Name:TORI
Middle Name:ALEXANDRA
Last Name:PHELPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-2427
Mailing Address - Country:US
Mailing Address - Phone:812-664-4312
Mailing Address - Fax:
Practice Address - Street 1:2324 PROSPECT STREET
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239
Practice Address - Country:US
Practice Address - Phone:812-664-4312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-18-30709103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst