Provider Demographics
NPI:1831421684
Name:PHILLIPS DAVIS, ANGELNELLE S
Entity type:Individual
Prefix:MRS
First Name:ANGELNELLE
Middle Name:S
Last Name:PHILLIPS DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ANGIE
Other - Middle Name:S
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6412 LARRYCREST DR
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-9719
Mailing Address - Country:US
Mailing Address - Phone:281-468-1922
Mailing Address - Fax:
Practice Address - Street 1:6412 LARRYCREST DR
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-9719
Practice Address - Country:US
Practice Address - Phone:281-468-1922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15493798103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities