Provider Demographics
NPI:1275074601
Name:MINER, PHYLLIS MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:MARIE
Last Name:MINER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:MARIE
Other - Last Name:MINER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:16633 89TH AVE
Mailing Address - Street 2:9C
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-4255
Mailing Address - Country:US
Mailing Address - Phone:347-724-2070
Mailing Address - Fax:
Practice Address - Street 1:16633 89TH AVE
Practice Address - Street 2:9C
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4255
Practice Address - Country:US
Practice Address - Phone:347-724-2070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-18
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0483591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical