Provider Demographics
NPI:1558410282
Name:PHILLIPS, STACY L (PHD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:L
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 SHOREHAM WAY
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-5030
Mailing Address - Country:US
Mailing Address - Phone:516-524-2881
Mailing Address - Fax:
Practice Address - Street 1:111 SHOREHAM WAY
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-5030
Practice Address - Country:US
Practice Address - Phone:516-524-2881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015915103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical