Provider Demographics
NPI:1093499808
Name:PHILLIPS, SHAVONNE (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:SHAVONNE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 REVERE VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-3445
Mailing Address - Country:US
Mailing Address - Phone:937-901-2160
Mailing Address - Fax:
Practice Address - Street 1:850 REVERE VILLAGE CT
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458-3445
Practice Address - Country:US
Practice Address - Phone:937-901-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.23093211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical