Provider Demographics
NPI:1184212888
Name:PHILLIPS, HEIDI LYNN
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:LYNN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:LYNN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:740 E GENERAL STEWART WAY STE 202
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-2630
Mailing Address - Country:US
Mailing Address - Phone:912-294-4055
Mailing Address - Fax:866-467-4321
Practice Address - Street 1:740 E GENERAL STEWART WAY STE 202
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-2630
Practice Address - Country:US
Practice Address - Phone:912-294-4055
Practice Address - Fax:866-467-4321
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-147786106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician