1750917027 NPI number — ANTHONIE JUSTIN PHILLIS LCPC, LADC

Table of content: ANTHONIE JUSTIN PHILLIS LCPC, LADC (NPI 1750917027)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750917027 NPI number — ANTHONIE JUSTIN PHILLIS LCPC, LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILLIS
Provider First Name:
ANTHONIE
Provider Middle Name:
JUSTIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC, LADC
Provider Gender Code:
M

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:
1750917027
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
275 MAIN STREET, SUITE 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIDDEFORD
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-391-0347
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
281 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIDDEFORD
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-494-8010
Provider Business Practice Location Address Fax Number:
207-494-8471
Provider Enumeration Date:
03/19/2020

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: 101YA0400X , with the licence number:  CAC6938 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: CC7079 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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