Provider Demographics
NPI:1518614379
Name:PHILLIPS, DOROTHY MARIE
Entity Type:Individual
Prefix:
First Name:DOROTHY
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 1:919 MITCHELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHINA GROVE
Mailing Address - State:NC
Mailing Address - Zip Code:28023-7418
Mailing Address - Country:US
Mailing Address - Phone:330-506-5252
Mailing Address - Fax:
Practice Address - Street 1:919 MITCHELL AVE
Practice Address - Street 2:
Practice Address - City:CHINA GROVE
Practice Address - State:NC
Practice Address - Zip Code:28023-7418
Practice Address - Country:US
Practice Address - Phone:330-704-8591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TM1800X
NC76732164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities