Provider Demographics
NPI:1649459496
Name:PHELAN, LINDA E (MFTI)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:E
Last Name:PHELAN
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11117 MAUREEN DR
Mailing Address - Street 2:
Mailing Address - City:CHERRY VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92223-5535
Mailing Address - Country:US
Mailing Address - Phone:951-845-2725
Mailing Address - Fax:
Practice Address - Street 1:6355 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3163
Practice Address - Country:US
Practice Address - Phone:951-369-5714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIMF 49277OtherMFT INTERN