Provider Demographics
NPI:1073051256
Name:PHILLIPS, STACEY L
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
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 1:185 BRONX RIVER RD
Mailing Address - Street 2:4P
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10704-3752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:185 BRONX RIVER RD
Practice Address - Street 2:4P
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10704-3752
Practice Address - Country:US
Practice Address - Phone:914-888-6811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2526005252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency