Basic Information
Provider Information | |||||||||
NPI: | 1194963009 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PHILLIPS | ||||||||
FirstName: | EARNEST | ||||||||
MiddleName: | RAY | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | B.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PHILLIPS | ||||||||
OtherFirstName: | EARNEST | ||||||||
OtherMiddleName: | RAY | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: | JR. | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 940 AVENUE 64 | ||||||||
Address2: |   | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 91105 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3232542274 | ||||||||
FaxNumber: | 3232549087 | ||||||||
Practice Location | |||||||||
Address1: | 940 AVENUE 64 | ||||||||
Address2: |   | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 91105 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3232542274 | ||||||||
FaxNumber: | 3232549087 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2009 | ||||||||
LastUpdateDate: | 07/18/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor |   | 225400000X |   | CA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |   |
No ID Information.