Provider Demographics
NPI:1134499528
Name:PHILLIPS, TRACIE A (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:A
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 HAGAN DR
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-5028
Mailing Address - Country:US
Mailing Address - Phone:845-463-7805
Mailing Address - Fax:
Practice Address - Street 1:42 HAGAN DR
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-5028
Practice Address - Country:US
Practice Address - Phone:845-463-7805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP05766911041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool