1760746952 NPI number — MRS. STEPHANIE G PHILLIPS M.A., J.D., LMFT

Table of content: MRS. STEPHANIE G PHILLIPS M.A., J.D., LMFT (NPI 1760746952)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760746952 NPI number — MRS. STEPHANIE G PHILLIPS M.A., J.D., LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILLIPS
Provider First Name:
STEPHANIE
Provider Middle Name:
G
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A., J.D., LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRANT
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760746952
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 SUMMER PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04103-4707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-374-1827
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 BISHOP ST
Provider Second Line Business Practice Location Address:
SUITE 16
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04103-2614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-374-1827
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2012

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: 106H00000X , with the licence number:  MF3166 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 106H00000X , with the licence number: MFC35186 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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