Provider Demographics
NPI:1184650665
Name:PRYSE, PHILLIP (LSW, CDCA)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:PRYSE
Suffix:
Gender:M
Credentials:LSW, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 OREGONIA RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-3903
Mailing Address - Country:US
Mailing Address - Phone:513-695-2411
Mailing Address - Fax:513-695-2309
Practice Address - Street 1:201 READING RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-1666
Practice Address - Country:US
Practice Address - Phone:513-398-2551
Practice Address - Fax:513-459-7300
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS-313421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000327213OtherANTHEM PIN
OH160633492199OtherHUMANA PROVIDER ID