Provider Demographics
NPI:1174859458
Name:PHILLIPS, ATHENA (LCSW)
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:
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 1:3583 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1820
Mailing Address - Country:US
Mailing Address - Phone:503-819-4181
Mailing Address - Fax:503-827-0299
Practice Address - Street 1:3583 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1820
Practice Address - Country:US
Practice Address - Phone:503-819-4181
Practice Address - Fax:503-827-0299
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL4462101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health