Provider Demographics
NPI:1437201993
Name:PREWETTE, PHILIP A (MA)
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:A
Last Name:PREWETTE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 HILL ST SE STE B
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-3292
Mailing Address - Country:US
Mailing Address - Phone:541-704-7304
Mailing Address - Fax:541-248-3467
Practice Address - Street 1:1123 HILL ST SE STE B
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-3292
Practice Address - Country:US
Practice Address - Phone:541-704-7304
Practice Address - Fax:541-248-3467
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2018-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST0389106H00000X
ORT0751106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist