Provider Demographics
NPI:1013964568
Name:PHILLIPS, DONNA JEAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:JEAN
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 1:1555 N TREASURE DR APT 410
Mailing Address - Street 2:
Mailing Address - City:NORTH BAY VILLAGE
Mailing Address - State:FL
Mailing Address - Zip Code:33141-4184
Mailing Address - Country:US
Mailing Address - Phone:305-793-5474
Mailing Address - Fax:305-867-7582
Practice Address - Street 1:1555 N TREASURE DR APT 410
Practice Address - Street 2:
Practice Address - City:NORTH BAY VILLAGE
Practice Address - State:FL
Practice Address - Zip Code:33141-4184
Practice Address - Country:US
Practice Address - Phone:305-793-5474
Practice Address - Fax:305-867-7582
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5255103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59765YMedicare PIN
FL59765Medicare ID - Type Unspecified