=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093411092
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY JENNIFER PHILLIPS LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2023
-----------------------------------------------------
Last Update Date | 02/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10775 PIONEER TRL STE 215
-----------------------------------------------------
City | TRUCKEE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96161-0234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-424-4266
-----------------------------------------------------
Fax | 415-520-6633
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9100 S DADELAND BLVD STE 1500
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33156-7816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-424-4266
-----------------------------------------------------
Fax | 415-520-6633
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149023819
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041S0200X
-----------------------------------------------------
Taxonomy Name | School Social Worker
-----------------------------------------------------
License Number | 1463192
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW20260
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------