Provider Demographics
NPI:1295486009
Name:PHILLIPS, DAVID PEEAIR (MCC, EDD, PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:PEEAIR
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MCC, EDD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 DORCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:TOBYHANNA
Mailing Address - State:PA
Mailing Address - Zip Code:18466-8218
Mailing Address - Country:US
Mailing Address - Phone:570-242-5098
Mailing Address - Fax:
Practice Address - Street 1:1187 POCONO BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT POCONO
Practice Address - State:PA
Practice Address - Zip Code:18344-1046
Practice Address - Country:US
Practice Address - Phone:570-242-5098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA16663101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2972261Medicaid