Healthcare Provider Details

I. General information

NPI: 1265290571
Provider Name (Legal Business Name): DANIEL TRAVIS PHILLIPS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3318
US

IV. Provider business mailing address

1500 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3318
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-4151
  • Fax:
Mailing address:
  • Phone: 573-686-4151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2021031639
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2024020481
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: