MEDICARE: MRS. GWENDOLYN PHILLIPS M.A, MCAP, IMH 9889

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	ADC-012635-2016	FL
2	101YM0800X	Mental Health Counselor	IMH 9889	FL

General Provider Information

NPI Number	:	1730411638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GWENDOLYN PHILLIPS M.A, MCAP, IMH 9889

Provider Business Mailing Address
First Line	:	1280 N CONGRESS AVE
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-6377
Country	:	US
Telephone Number	:	561-228-1598
Fax Number	:

Provider Business Practice Location Address
First Line	:	1280 N CONGRESS AVE
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-6377
Country	:	US
Telephone Number	:	561-228-1598
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2010
Last Update Date	:	02/22/2017

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