Provider Demographics
NPI:1467818484
Name:PHILLIPS, ADAM
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:PHILLIPS
Suffix:
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 1:401 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-3502
Mailing Address - Country:US
Mailing Address - Phone:918-649-0230
Mailing Address - Fax:
Practice Address - Street 1:2202 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2000
Practice Address - Country:US
Practice Address - Phone:918-649-0018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-06
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OK10220101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator