Provider Demographics
NPI:1063019784
Name:PHILLIPS, CHARLENE
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 WOODLYTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:DE
Mailing Address - Zip Code:19962-1622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:702 WOODLYTOWN RD
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:DE
Practice Address - Zip Code:19962-1622
Practice Address - Country:US
Practice Address - Phone:302-573-1231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE2505446377Medicaid