Healthcare Provider Details

I. General information

NPI: 1154351104
Provider Name (Legal Business Name): PHILIP GRIFFITH LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN HEALTHCARE SYSTEM,
JBLM WA
98431
US

IV. Provider business mailing address

3239 RIDGE DR
BEALE AFB CA
95903-2140
US

V. Phone/Fax

Practice location:
  • Phone: 618-719-5521
  • Fax:
Mailing address:
  • Phone: 618-719-5521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34553
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: