Healthcare Provider Details

I. General information

NPI: 1568639375
Provider Name (Legal Business Name): JO-ANN VENEZIA PHILLIPS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 MAIN ST UNIT 205
MEDWAY MA
02053-1584
US

IV. Provider business mailing address

165 MAIN ST UNIT 205
MEDWAY MA
02053-1584
US

V. Phone/Fax

Practice location:
  • Phone: 978-304-9283
  • Fax:
Mailing address:
  • Phone: 978-304-9283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number116231
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: