Provider Demographics
NPI:1932305901
Name:PHILLIPS, DIANE LYNN (EDD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:LYNN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 487 MANCHESTER 98353
Mailing Address - Street 2:1353 YUKON HARBOR SE
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366
Mailing Address - Country:US
Mailing Address - Phone:360-871-5494
Mailing Address - Fax:360-871-5499
Practice Address - Street 1:1353 YUKON HARBOR RD SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-8576
Practice Address - Country:US
Practice Address - Phone:360-871-5494
Practice Address - Fax:360-871-5499
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00006197101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health