Provider Demographics
NPI:1629803226
Name:PHILLIPS, QUARTAZE JR
Entity type:Individual
Prefix:
First Name:QUARTAZE
Middle Name:
Last Name:PHILLIPS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19251 MACK AVE # 450
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2893
Mailing Address - Country:US
Mailing Address - Phone:313-343-1370
Mailing Address - Fax:248-712-0438
Practice Address - Street 1:19251 MACK AVE # 450
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2893
Practice Address - Country:US
Practice Address - Phone:313-343-1370
Practice Address - Fax:248-712-0438
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician