Provider Demographics
NPI:1376327585
Name:PHILLIPS, MIRANDAH (LSW)
Entity Type:Individual
Prefix:
First Name:MIRANDAH
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 BRANCH BROOK DR # 297
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-3606
Mailing Address - Country:US
Mailing Address - Phone:862-304-0136
Mailing Address - Fax:
Practice Address - Street 1:297 BRANCH BROOK DR # 297
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-3606
Practice Address - Country:US
Practice Address - Phone:862-304-0136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06924300104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker