Provider Demographics
NPI:1982742144
Name:OWENS, PHYLLIS ANN (MA LP)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:ANN
Last Name:OWENS
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-0247
Mailing Address - Country:US
Mailing Address - Phone:612-965-7954
Mailing Address - Fax:
Practice Address - Street 1:211151 JOHN MILLESS DRIVE
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:56374
Practice Address - Country:US
Practice Address - Phone:612-965-7954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0894103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN67B020WOtherBSBC I
MN67B010WOtherBSBCG
MN6235443OtherMEDICA