Provider Demographics
NPI:1407318777
Name:PHILLIPS, MARCUS JERMAINE
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:JERMAINE
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 W 135TH ST APT 4A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-2847
Mailing Address - Country:US
Mailing Address - Phone:917-379-4775
Mailing Address - Fax:
Practice Address - Street 1:356 W 18TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-4401
Practice Address - Country:US
Practice Address - Phone:212-271-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY08792611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical