Basic Information
| Provider Information | |||||||||
| NPI: | 1003564741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10564 SE WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972162809 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3910 SE STARK ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972142278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032289229 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2022 | ||||||||
| LastUpdateDate: | 03/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 175T00000X | N | 175T00000X | 21-CRM-572 | OR | Y |
No ID Information.