Healthcare Provider Details

I. General information

NPI: 1013555341
Provider Name (Legal Business Name): ANGINESE DAVINE PHILLIPS MS, LCAT, BC-DMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 MADISON AVE RM 608
NEW YORK NY
10016-0800
US

IV. Provider business mailing address

115 E 122ND ST APT 5A
NEW YORK NY
10035-2824
US

V. Phone/Fax

Practice location:
  • Phone: 646-389-5801
  • Fax:
Mailing address:
  • Phone: 917-574-1185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225600000X
TaxonomyDance Therapist
License Number001952
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: