Provider Demographics
NPI:1730379892
Name:PHILLIPS, MORAIMA D (MED, MS)
Entity type:Individual
Prefix:
First Name:MORAIMA
Middle Name:D
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MED, MS
Other - Prefix:
Other - First Name:MORAIMA
Other - Middle Name:DANIEL
Other - Last Name:VASQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:107 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1510
Mailing Address - Country:US
Mailing Address - Phone:509-838-4651
Mailing Address - Fax:509-363-2762
Practice Address - Street 1:107 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202
Practice Address - Country:US
Practice Address - Phone:509-838-4651
Practice Address - Fax:509-363-2762
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00010379101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1730379892Medicaid
WA31910060OtherMEDICARE GROUP