Provider Demographics
NPI:1710685656
Name:FILLMORE, PHOEBE TERRILL
Entity Type:Individual
Prefix:
First Name:PHOEBE
Middle Name:TERRILL
Last Name:FILLMORE
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 1:3820 N TUPIZA AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-4808
Mailing Address - Country:US
Mailing Address - Phone:626-497-4119
Mailing Address - Fax:
Practice Address - Street 1:4974 S BITTERCREEK AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7970
Practice Address - Country:US
Practice Address - Phone:208-870-3379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician