Provider Demographics
NPI:1750448783
Name:CAZARES, PHYLLIS R (PHD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:R
Last Name:CAZARES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2707
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31793-2707
Mailing Address - Country:US
Mailing Address - Phone:229-388-0932
Mailing Address - Fax:229-388-0933
Practice Address - Street 1:216 8TH STREET WEST
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794
Practice Address - Country:US
Practice Address - Phone:229-388-0932
Practice Address - Fax:229-388-0933
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002556103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000936207CMedicaid
GAP37152Medicare UPIN
GA000936207CMedicaid
GA000936207CMedicare PIN