Provider Demographics
NPI:1417019795
Name:PHILLIPS, GENA PITTMAN (LPC, LCAS, CCS)
Entity Type:Individual
Prefix:MRS
First Name:GENA
Middle Name:PITTMAN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LPC, LCAS, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 ANDERBY DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27527-7011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1662 BOOKER DAIRY RD
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-9405
Practice Address - Country:US
Practice Address - Phone:919-938-0046
Practice Address - Fax:919-938-0056
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC887101YA0400X
NC5334101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5334OtherLPC
NC6103397Medicaid
NC887OtherLCAS