Provider Demographics
NPI:1265504302
Name:PHILLIPS, MARY ELIZABETH (MA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 SUMMERFIELD LN
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-1699
Mailing Address - Country:US
Mailing Address - Phone:618-467-2928
Mailing Address - Fax:
Practice Address - Street 1:611 W. DELMAR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002
Practice Address - Country:US
Practice Address - Phone:618-806-8822
Practice Address - Fax:618-589-2205
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-002722101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor