Provider Demographics
NPI:1134790355
Name:SOLE, PHILLIP D JR (CMT,NAA)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:D
Last Name:SOLE
Suffix:JR
Gender:M
Credentials:CMT,NAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5645 BRECKENRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-2421
Mailing Address - Country:US
Mailing Address - Phone:702-937-5327
Mailing Address - Fax:
Practice Address - Street 1:5645 BRECKENRIDGE ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89081-2421
Practice Address - Country:US
Practice Address - Phone:702-937-5327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty