Healthcare Provider Details

I. General information

NPI: 1356519946
Provider Name (Legal Business Name): MS. DEBRA PHILLIPS SR.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 02/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 NIAGARA STREET DRUG & ALCOHOL ABUSE SERV. ADOLESCENT OUTPATIENT PRG.
BUFFALO NY
14213
US

IV. Provider business mailing address

254 FRANKLIN STREET LAKE SHORE BEHAVIORAL HEALTH
BUFFALO NY
14202
US

V. Phone/Fax

Practice location:
  • Phone: 716-883-5344
  • Fax: 716-884-1758
Mailing address:
  • Phone: 716-842-0440
  • Fax: 716-842-4069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number062738-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: