Provider Demographics
NPI:1821475211
Name:PHILLIPS, CATRIN TREVENA (RADT1)
Entity Type:Individual
Prefix:MISS
First Name:CATRIN
Middle Name:TREVENA
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RADT1
Other - Prefix:MISS
Other - First Name:CATRIN
Other - Middle Name:TREVENA
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RADT-1
Mailing Address - Street 1:9370 MARLEMONT CIR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-7605
Mailing Address - Country:US
Mailing Address - Phone:916-531-9130
Mailing Address - Fax:
Practice Address - Street 1:9370 MARLEMONT CIR
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7605
Practice Address - Country:US
Practice Address - Phone:916-691-3131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1193410215101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1215287933OtherMEDICAL