Healthcare Provider Details

I. General information

NPI: 1760903827
Provider Name (Legal Business Name): MARY PHILLIPS LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 06/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2316 S CEDAR ST
LANSING MI
48910-3152
US

IV. Provider business mailing address

PO BOX 30161
LANSING MI
48909-7661
US

V. Phone/Fax

Practice location:
  • Phone: 517-887-4302
  • Fax: 517-887-4437
Mailing address:
  • Phone: 517-364-8178
  • Fax: 517-244-7174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801101422
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: