MEDICARE: MR. DOUGLAS AUSTIN PHILLIPS L.C.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCS11700	CA

General Provider Information

NPI Number	:	1356641955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOUGLAS AUSTIN PHILLIPS L.C.S.W.

Provider Business Mailing Address
First Line	:	17600 YELLOW PINE AVE
Second Line	:
City	:	SHASTA LAKE
State	:	CA
Zip	:	96019-2074
Country	:	US
Telephone Number	:	530-356-9133
Fax Number	:	530-528-2938

Provider Business Practice Location Address
First Line	:	590 ANTELOPE BLVD
Second Line	:	B30
City	:	RED BLUFF
State	:	CA
Zip	:	96080-2474
Country	:	US
Telephone Number	:	530-529-9454
Fax Number	:	530-529-9456

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2010
Last Update Date	:	10/28/2010

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