Healthcare Provider Details

I. General information

NPI: 1184033409
Provider Name (Legal Business Name): PHYLLISTINE ANNETTE OLIVER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2014
Last Update Date: 08/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 EDUCATION DR BEACON CITY SCHOOL DISTRICT
BEACON NY
12508-4067
US

IV. Provider business mailing address

29 EDUCATION DR BEACON CITY SCHOOL DISTRICT
BEACON NY
12508-4067
US

V. Phone/Fax

Practice location:
  • Phone: 845-838-6900
  • Fax: 845-838-6978
Mailing address:
  • Phone: 845-838-6900
  • Fax: 845-838-6978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number080303-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: