Provider Demographics
NPI:1770640179
Name:PHILLIPS, VIVIEN JOHNETTE (PSYD)
Entity Type:Individual
Prefix:
First Name:VIVIEN
Middle Name:JOHNETTE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26332 135TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98042-3518
Mailing Address - Country:US
Mailing Address - Phone:253-630-8118
Mailing Address - Fax:
Practice Address - Street 1:195 NE GILMAN BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2940
Practice Address - Country:US
Practice Address - Phone:425-391-8611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1265103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical