Healthcare Provider Details

I. General information

NPI: 1710268651
Provider Name (Legal Business Name): PHYLLIS PALMER MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

668 N ORLANDO AVE STE 210
MAITLAND FL
32751-4459
US

IV. Provider business mailing address

3615 VALLEYVIEW DR
KISSIMMEE FL
34746-2896
US

V. Phone/Fax

Practice location:
  • Phone: 407-215-0095
  • Fax:
Mailing address:
  • Phone: 660-229-0449
  • Fax: 407-261-0523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: