Provider Demographics
NPI:1447607668
Name:PHILLIPS, SHANNON
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SHANNON-MARIE
Other - Middle Name:
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10 MEADOWBROOK RD
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-7122
Mailing Address - Country:US
Mailing Address - Phone:774-213-8337
Mailing Address - Fax:
Practice Address - Street 1:10 MEADOWBROOK RD
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7122
Practice Address - Country:US
Practice Address - Phone:774-213-8337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator