Provider Demographics
NPI:1467118075
Name:PHILLIPS, EDWARD J (CYC, CIT-HS-00158)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:CYC, CIT-HS-00158
Other - Prefix:MR
Other - First Name:EDWARD
Other - Middle Name:J
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 251970
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72225
Mailing Address - Country:US
Mailing Address - Phone:501-666-8686
Mailing Address - Fax:501-660-6830
Practice Address - Street 1:1521 MERRILL DRIVE
Practice Address - Street 2:STE D220
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211
Practice Address - Country:US
Practice Address - Phone:501-666-8686
Practice Address - Fax:501-660-6830
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARCIT-HS-00158101YA0400X
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1831727890OtherAMBETTER, BLUE CROSS BLUE SHIELD