Basic Information
| Provider Information | |||||||||
| NPI: | 1124221643 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEGRUY | ||||||||
| FirstName: | PHINNILLIPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1901 CHURCH LN | ||||||||
| Address2: | |||||||||
| City: | SAN PABLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 948063707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102363139 | ||||||||
| FaxNumber: | 5102363200 | ||||||||
| Practice Location | |||||||||
| Address1: | 127 GRENADINE WAY | ||||||||
| Address2: | |||||||||
| City: | HERCULES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945472041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107991570 | ||||||||
| FaxNumber: | 5107991866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.