1285784629 NPI number — CARRIE A PHILLIPS LISW

Table of content: CARRIE A PHILLIPS LISW (NPI 1285784629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285784629 NPI number — CARRIE A PHILLIPS LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILLIPS
Provider First Name:
CARRIE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285784629
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 LINCOLN PARK BLVD STE 208
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KETTERING
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45429-3479
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-293-4199
Provider Business Mailing Address Fax Number:
937-298-6271

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 LINCOLN PARK BLVD STE 208
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KETTERING
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45429-3479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-293-4199
Provider Business Practice Location Address Fax Number:
937-298-6271
Provider Enumeration Date:
01/10/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  I0008753 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000372382 . This is a "ANTHEM BC BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".