Healthcare Provider Details

I. General information

NPI: 1356008759
Provider Name (Legal Business Name): STEPHANIE PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2021
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 N ROLLING RD STE 305
CATONSVILLE MD
21228-4142
US

IV. Provider business mailing address

3 GONDOLA VIEW CT
WOODSTOCK MD
21163-1136
US

V. Phone/Fax

Practice location:
  • Phone: 410-371-6091
  • Fax:
Mailing address:
  • Phone: 410-371-6091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLGA3011
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGA3011
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: