Provider Demographics
NPI:1205209434
Name:PHILLIPS, DALVINA GREEN (MS, LPC)
Entity Type:Individual
Prefix:
First Name:DALVINA
Middle Name:GREEN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 HILLSBOROUGH RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-3639
Mailing Address - Country:US
Mailing Address - Phone:864-275-6528
Mailing Address - Fax:
Practice Address - Street 1:1721 SHIVERS RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-5413
Practice Address - Country:US
Practice Address - Phone:803-896-7462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-10
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
SC6450101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist