Provider Demographics
NPI:1861956146
Name:PHILLIPS, CICELY EBONEE
Entity type:Individual
Prefix:
First Name:CICELY
Middle Name:EBONEE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 HAWTHORNE ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-2616
Mailing Address - Country:US
Mailing Address - Phone:925-352-6838
Mailing Address - Fax:
Practice Address - Street 1:459 HAWTHORNE ST
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:CA
Practice Address - Zip Code:94565-2616
Practice Address - Country:US
Practice Address - Phone:209-423-4277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA118770390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist