Healthcare Provider Details

I. General information

NPI: 1306847033
Provider Name (Legal Business Name): PHYLLIS WADDELL MURRAY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 HARMON AVE
FT STEWART GA
31314-5604
US

IV. Provider business mailing address

403 ROGERS RD
HINESVILLE GA
31313-3731
US

V. Phone/Fax

Practice location:
  • Phone: 912-435-6779
  • Fax: 912-435-6863
Mailing address:
  • Phone: 912-369-0473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number000655
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: