Provider Demographics
NPI:1205390986
Name:MORT, PHYLLIS MARIE (LAC)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:MARIE
Last Name:MORT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:667 ROUTE 292
Mailing Address - Street 2:
Mailing Address - City:HOLMES
Mailing Address - State:NY
Mailing Address - Zip Code:12531-5342
Mailing Address - Country:US
Mailing Address - Phone:914-282-8493
Mailing Address - Fax:
Practice Address - Street 1:667 ROUTE 292
Practice Address - Street 2:
Practice Address - City:HOLMES
Practice Address - State:NY
Practice Address - Zip Code:12531-5342
Practice Address - Country:US
Practice Address - Phone:914-282-8493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-26
Last Update Date:2019-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006053-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist