Provider Demographics
NPI:1720136583
Name:PHILLIPS, MINDY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MINDY
Middle Name:
Last Name:PHILLIPS
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 1:26 ARIZONA AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-1403
Mailing Address - Country:US
Mailing Address - Phone:516-763-2764
Mailing Address - Fax:
Practice Address - Street 1:26 ARIZONA AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-1403
Practice Address - Country:US
Practice Address - Phone:516-763-2764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010620103TC0700X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6800700OtherGHIPIN