Healthcare Provider Details

I. General information

NPI: 1821099771
Provider Name (Legal Business Name): MARTHA PHILLIPS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3610 W VILLAGE TER
SPRINGFIELD MO
65810-1027
US

IV. Provider business mailing address

3610 W VILLAGE TER
SPRINGFIELD MO
65810-1027
US

V. Phone/Fax

Practice location:
  • Phone: 417-882-9343
  • Fax:
Mailing address:
  • Phone: 417-882-9343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002172
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: