Provider Demographics
NPI:1265405195
Name:PHILLIPS, GERALYN MARIE (PHD)
Entity type:Individual
Prefix:
First Name:GERALYN
Middle Name:MARIE
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 1:8439 WHITE OAK AVE
Mailing Address - Street 2:#104
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3860
Mailing Address - Country:US
Mailing Address - Phone:909-466-7624
Mailing Address - Fax:
Practice Address - Street 1:8439 WHITE OAK AVE
Practice Address - Street 2:#104
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3860
Practice Address - Country:US
Practice Address - Phone:909-466-7624
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 17167103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL171670Medicare UPIN