Healthcare Provider Details

I. General information

NPI: 1033997895
Provider Name (Legal Business Name): ANDREW JAY PHIPPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2023
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 LAFAYETTE CIR
GEORGETOWN SC
29440-2569
US

IV. Provider business mailing address

3718 N FRASER ST
GEORGETOWN SC
29440-6647
US

V. Phone/Fax

Practice location:
  • Phone: 843-240-2322
  • Fax:
Mailing address:
  • Phone: 843-240-2322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: