Provider Demographics
NPI:1225361314
Name:PHILLIPS, GENEIVA DIANNE (LMFT)
Entity Type:Individual
Prefix:DR
First Name:GENEIVA
Middle Name:DIANNE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6825 EASTLAKE RD
Mailing Address - Street 2:
Mailing Address - City:STERLINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:71280-3205
Mailing Address - Country:US
Mailing Address - Phone:318-665-2805
Mailing Address - Fax:318-665-2805
Practice Address - Street 1:6825 EASTLAKE RD
Practice Address - Street 2:
Practice Address - City:STERLINGTON
Practice Address - State:LA
Practice Address - Zip Code:71280-3205
Practice Address - Country:US
Practice Address - Phone:318-665-2805
Practice Address - Fax:318-665-2805
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA163101YM0800X, 106H00000X
TX4011101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA72-1160331OtherTIN