Provider Demographics
NPI:1538213947
Name:PHILLIPS, LASCELLS MARTIN (LCSW)
Entity type:Individual
Prefix:MR
First Name:LASCELLS
Middle Name:MARTIN
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:472 TULANE DR
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-4024
Mailing Address - Country:US
Mailing Address - Phone:407-389-0068
Mailing Address - Fax:
Practice Address - Street 1:315 N LAKEMONT AVE
Practice Address - Street 2:STE.B
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3205
Practice Address - Country:US
Practice Address - Phone:407-830-6412
Practice Address - Fax:407-830-8413
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW84171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW8417OtherLCSW