=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568661411
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARELLA PHILLIPS MSW, LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2007
-----------------------------------------------------
Last Update Date | 04/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 PIEDMONT AVE
-----------------------------------------------------
City | GIBSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27249-2450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-449-6150
-----------------------------------------------------
Fax | 336-449-7368
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1392 TAYLOR HEATH RD
-----------------------------------------------------
City | KINSTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28501-7151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-449-6150
-----------------------------------------------------
Fax | 336-449-7368
-----------------------------------------------------
=====================================================
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 | P003837
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C006629
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------