Provider Demographics
NPI:1013555341
Name:PHILLIPS, ANGINESE DAVINE (MS, LCAT, BC-DMT)
Entity Type:Individual
Prefix:MS
First Name:ANGINESE
Middle Name:DAVINE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MS, LCAT, BC-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E 122ND ST APT 5A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-2824
Mailing Address - Country:US
Mailing Address - Phone:917-574-1185
Mailing Address - Fax:
Practice Address - Street 1:280 MADISON AVE RM 608
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-0800
Practice Address - Country:US
Practice Address - Phone:646-389-5801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0700X
NY001952225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging