Healthcare Provider Details

I. General information

NPI: 1184650665
Provider Name (Legal Business Name): PHILLIP PRYSE LSW, CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 READING RD
MASON OH
45040-1666
US

IV. Provider business mailing address

107 OREGONIA RD 2ND FLOOR
LEBANON OH
45036-3903
US

V. Phone/Fax

Practice location:
  • Phone: 513-398-2551
  • Fax: 513-459-7300
Mailing address:
  • Phone: 513-695-2411
  • Fax: 513-695-2309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS-31342
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: