Provider Demographics
NPI:1013081819
Name:PHILLIPS, WALTOR M (PH D)
Entity Type:Individual
Prefix:DR
First Name:WALTOR
Middle Name:M
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MIDDLEBURY ROAD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762
Mailing Address - Country:US
Mailing Address - Phone:203-758-8333
Mailing Address - Fax:203-758-8333
Practice Address - Street 1:415 MIDDLEBURY ROAD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762
Practice Address - Country:US
Practice Address - Phone:203-758-8333
Practice Address - Fax:203-758-8333
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT621103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical