Provider Demographics
NPI:1538350194
Name:PHILLIPS, PHILIP JOHN (LMSW)
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:JOHN
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9447 WHITALL LN
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-1276
Mailing Address - Country:US
Mailing Address - Phone:734-837-7126
Mailing Address - Fax:
Practice Address - Street 1:9447 WHITALL LN
Practice Address - Street 2:
Practice Address - City:GROSSE ILE
Practice Address - State:MI
Practice Address - Zip Code:48138-1276
Practice Address - Country:US
Practice Address - Phone:734-837-7126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010177521041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION75240Medicare PIN