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General NPI Number Information
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NPI Number | 1053941690
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Entity Type | Individual
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Provider Name | PHYLLIS RITA VENTOCILLA LMSW
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Gender | Female
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Dates
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Enumeration Date | 01/23/2020
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Last Update Date | 01/23/2020
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Provider Practice Location Address
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Address Line | 1050 W WESTERN AVE STE 400
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City | MUSKEGON
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State | MI
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Zip | 49441-1666
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Country | US
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Telephone | 231-728-3442
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Fax |
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Provider Business Mailing Address
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Address Line | 15686 RIVER SIDE DR
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City | SPRING LAKE
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State | MI
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Zip | 49456-9243
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Country | US
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Telephone | 231-728-3442
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 6801061129
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License Number State | MI
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