Healthcare Provider Details

I. General information

NPI: 1972373777
Provider Name (Legal Business Name): MICHAEL BLAINE PHILLIPS CSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

748 N 1340 W
OREM UT
84057-6101
US

IV. Provider business mailing address

748 N 1340 W
OREM UT
84057-6101
US

V. Phone/Fax

Practice location:
  • Phone: 801-882-3104
  • Fax:
Mailing address:
  • Phone: 801-882-3104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12591213-3502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: