Provider Demographics
NPI:1497975205
Name:PHILLIPS, GLYNIS MARIE
Entity Type:Individual
Prefix:MS
First Name:GLYNIS
Middle Name:MARIE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 W MANCHESTER BLVD
Mailing Address - Street 2:#104
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301
Mailing Address - Country:US
Mailing Address - Phone:310-412-0879
Mailing Address - Fax:
Practice Address - Street 1:614 W MANCHESTER BLVD
Practice Address - Street 2:#104
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301
Practice Address - Country:US
Practice Address - Phone:310-412-0879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7006Medicaid