Provider Demographics
NPI:1962834721
Name:UTUMAPU, PHILLIP SHACK (RAS)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:SHACK
Last Name:UTUMAPU
Suffix:
Gender:M
Credentials:RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13626 HOLMES ST APT 16
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-5567
Mailing Address - Country:US
Mailing Address - Phone:760-619-0663
Mailing Address - Fax:
Practice Address - Street 1:13626 HOLMES ST APT 16
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-5567
Practice Address - Country:US
Practice Address - Phone:760-619-0663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health