Provider Demographics
NPI:1013075290
Name:PHILLIPS, JUDY N (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDY
Middle Name:N
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 1:3525 DEL MAR HEIGHTS RD
Mailing Address - Street 2:BOX 113
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130
Mailing Address - Country:US
Mailing Address - Phone:619-220-2525
Mailing Address - Fax:858-558-0488
Practice Address - Street 1:5230 CARROLL CANYON RD
Practice Address - Street 2:#320
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121
Practice Address - Country:US
Practice Address - Phone:619-220-2525
Practice Address - Fax:858-558-0488
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5643103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00PL56430OtherBLUE SHIELD
CP5643Medicare ID - Type Unspecified