Provider Demographics
NPI:1326024118
Name:PHILLIPS, JOHN C (SW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 N CLAUDE A LORD BLVD
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-2706
Mailing Address - Country:US
Mailing Address - Phone:570-622-1025
Mailing Address - Fax:570-628-4344
Practice Address - Street 1:450 N CLAUDE A LORD BLVD
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2706
Practice Address - Country:US
Practice Address - Phone:570-622-1025
Practice Address - Fax:570-628-4344
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW001026E104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
645951Medicare ID - Type Unspecified