Healthcare Provider Details

I. General information

NPI: 1942942438
Provider Name (Legal Business Name): CANDY MICHELLE PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 S 70TH ST
FORT SMITH AR
72903-5017
US

IV. Provider business mailing address

PO BOX 11818
FORT SMITH AR
72917-1818
US

V. Phone/Fax

Practice location:
  • Phone: 794-526-6504
  • Fax: 479-785-9495
Mailing address:
  • Phone: 479-452-6650
  • Fax: 479-785-9495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number12966-M
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: