Provider Demographics
NPI:1023724218
Name:PHELPS, MAURA ELIZABETH (MT-BC)
Entity type:Individual
Prefix:
First Name:MAURA
Middle Name:ELIZABETH
Last Name:PHELPS
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 XIMENO AVE APT 136
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-2135
Mailing Address - Country:US
Mailing Address - Phone:360-259-4432
Mailing Address - Fax:
Practice Address - Street 1:1611 XIMENO AVE APT 136
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2135
Practice Address - Country:US
Practice Address - Phone:360-259-4432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
16074225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist