Provider Demographics
NPI:1902258320
Name:PHILLIPS, RACHEL MIKAELA
Entity Type:Individual
Prefix:MISS
First Name:RACHEL
Middle Name:MIKAELA
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 CAMBORNE AVE NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1702
Mailing Address - Country:US
Mailing Address - Phone:850-226-2383
Mailing Address - Fax:
Practice Address - Street 1:629 CAMBORNE AVE NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1702
Practice Address - Country:US
Practice Address - Phone:850-226-2383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-09
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-45001103K00000X
FL0-17-8253106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst