Provider Demographics
NPI:1861749129
Name:MCLAURIN, PHYLLIS MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:MARIE
Last Name:MCLAURIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 CROSSWAYS BLVD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-2896
Mailing Address - Country:US
Mailing Address - Phone:757-410-0072
Mailing Address - Fax:757-410-7290
Practice Address - Street 1:1435 CROSSWAYS BLVD
Practice Address - Street 2:SUITE 109
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-2896
Practice Address - Country:US
Practice Address - Phone:757-410-0072
Practice Address - Fax:757-410-7290
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710101598101YA0400X
VA09040078331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical