Provider Demographics
NPI:1336823467
Name:YEBBA, PHILIP JR
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:YEBBA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 TREMONT ST APT 3
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-1144
Mailing Address - Country:US
Mailing Address - Phone:617-942-1094
Mailing Address - Fax:
Practice Address - Street 1:234 CABOT ST STE 202
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-5723
Practice Address - Country:US
Practice Address - Phone:617-942-1094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13336101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health