Provider Demographics
NPI:1205424744
Name:PHILLIPS, MELVIA A (MA)
Entity type:Individual
Prefix:
First Name:MELVIA
Middle Name:A
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7834 WILD EAGLE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78255-1233
Mailing Address - Country:US
Mailing Address - Phone:210-296-0126
Mailing Address - Fax:
Practice Address - Street 1:16607 BLANCO RD STE 1107
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1961
Practice Address - Country:US
Practice Address - Phone:210-816-4149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX83872101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional