MEDICARE: DENNIS RAY PHILLIPS LCSW

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	1178	TX

General Provider Information

NPI Number	:	1639327877
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENNIS RAY PHILLIPS LCSW

Provider Business Mailing Address
First Line	:	5656 N JACKSON ST
Second Line	:
City	:	JACKSONVILLE
State	:	TX
Zip	:	75766-9641
Country	:	US
Telephone Number	:	903-589-9000
Fax Number	:	903-589-3443

Provider Business Practice Location Address
First Line	:	5656 N JACKSON ST
Second Line	:
City	:	JACKSONVILLE
State	:	TX
Zip	:	75766-9641
Country	:	US
Telephone Number	:	903-589-9000
Fax Number	:	903-589-3443

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

Provider Enumeration Date	:	08/29/2008
Last Update Date	:	08/29/2008

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