Provider Demographics
NPI:1164761904
Name:PHILLIPS, TISHA (MSW, LCSWA)
Entity Type:Individual
Prefix:
First Name:TISHA
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3093 TETON DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-0016
Mailing Address - Country:US
Mailing Address - Phone:980-522-3474
Mailing Address - Fax:
Practice Address - Street 1:2020 REMOUNT RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7476
Practice Address - Country:US
Practice Address - Phone:704-842-6354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0078841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical