Provider Demographics
NPI:1336297696
Name:PHILLIPS, DENNIS (LCSW)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 A SHILOH PIKE
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302
Mailing Address - Country:US
Mailing Address - Phone:856-451-5511
Mailing Address - Fax:856-451-3589
Practice Address - Street 1:704 SHILOH PIKE # A
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-1460
Practice Address - Country:US
Practice Address - Phone:856-451-5511
Practice Address - Fax:856-451-3589
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SCO13385001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ038697Medicare ID - Type Unspecified