1649344995 NPI number — TRICIA L PHILLIPS LPC, NCC, CCJP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649344995 NPI number — TRICIA L PHILLIPS LPC, NCC, CCJP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILLIPS
Provider First Name:
TRICIA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC, NCC, CCJP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOLERJACK
Provider Other First Name:
TRICIA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649344995
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11825 PRIVATE DRIVE 5136
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROLLA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65401-5909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-647-1746
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13160 COUNTY RD. 3610
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST. JAMES
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65559-9989
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-265-3251
Provider Business Practice Location Address Fax Number:
573-265-8363
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  2005038745 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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