Provider Demographics
NPI:1932136108
Name:PHILLIPS, THERESA (PHD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:PHILLIPS
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 1:1 BAYWOOD AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-1537
Mailing Address - Country:US
Mailing Address - Phone:650-344-6961
Mailing Address - Fax:
Practice Address - Street 1:115 E RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94801-4034
Practice Address - Country:US
Practice Address - Phone:510-237-6865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 19723103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY19723OtherSTATE LICENSE