Provider Demographics
NPI:1538317490
Name:MONGAN, PHILIP C (LCSW)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:C
Last Name:MONGAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 15TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-5404
Mailing Address - Country:US
Mailing Address - Phone:218-330-1263
Mailing Address - Fax:
Practice Address - Street 1:1909 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-6151
Practice Address - Country:US
Practice Address - Phone:256-734-4688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-93732OtherBLUE CROSS BLUE SHIELD
AL330000025Medicaid