Provider Demographics
NPI:1629151634
Name:BALES, PHYLLIS BENTLEY (PHD)
Entity type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:BENTLEY
Last Name:BALES
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 1:718 42ND AVE NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-7707
Mailing Address - Country:US
Mailing Address - Phone:253-851-5502
Mailing Address - Fax:253-851-8108
Practice Address - Street 1:718 42ND AVE NW
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-7707
Practice Address - Country:US
Practice Address - Phone:253-851-5502
Practice Address - Fax:253-851-8108
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00003585101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health