Basic Information
Provider Information | |||||||||
NPI: | 1508343484 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TRAIL | ||||||||
FirstName: | PHYLLIS | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN, LMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4521 | ||||||||
Address2: |   | ||||||||
City: | CARSON CITY | ||||||||
State: | NV | ||||||||
PostalCode: | 897024521 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7758889148 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 850 MILL ST STE 100 | ||||||||
Address2: |   | ||||||||
City: | RENO | ||||||||
State: | NV | ||||||||
PostalCode: | 895021463 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7755386700 | ||||||||
FaxNumber: | 7756885878 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2018 | ||||||||
LastUpdateDate: | 07/24/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFT15312 | CA | N |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 163WP0808X | RN10245 | NV | Y |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.