Healthcare Provider Details

I. General information

NPI: 1033630579
Provider Name (Legal Business Name): JUSTIN DAVID PHILLIPS MAMFC, NCC, ALC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3396 MOUNT OLIVE RD
MOUNT OLIVE AL
35117-3710
US

IV. Provider business mailing address

554 WHITTAKER PL
LEEDS AL
35094-4928
US

V. Phone/Fax

Practice location:
  • Phone: 205-631-4126
  • Fax: 205-631-4156
Mailing address:
  • Phone: 678-779-8739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC2365A
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC2365A
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC2365A
License Number StateAL
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3758
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: