Provider Demographics
NPI:1013661164
Name:PAGE, PHILLIP (LSSP, NCSP)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:PAGE
Suffix:
Gender:M
Credentials:LSSP, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5707 ROYAL LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-5500
Mailing Address - Country:US
Mailing Address - Phone:214-265-4122
Mailing Address - Fax:
Practice Address - Street 1:5707 ROYAL LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75229-5500
Practice Address - Country:US
Practice Address - Phone:214-265-4122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70300103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool