Provider Demographics
NPI:1194817775
Name:PHILLIPS, AUDREY ANNE (LBSW RN)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:ANNE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LBSW RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10685 VELMA DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-9120
Mailing Address - Country:US
Mailing Address - Phone:616-225-2365
Mailing Address - Fax:
Practice Address - Street 1:375 APPLE TREE DR
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-7506
Practice Address - Country:US
Practice Address - Phone:616-527-1790
Practice Address - Fax:616-527-0538
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802080626104100000X
MI4704314040163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1715928Medicaid