Provider Demographics
NPI:1568661411
Name:PHILLIPS, MARELLA (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MARELLA
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1392 TAYLOR HEATH RD
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-7151
Mailing Address - Country:US
Mailing Address - Phone:336-449-6150
Mailing Address - Fax:336-449-7368
Practice Address - Street 1:111 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:GIBSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:27249-2450
Practice Address - Country:US
Practice Address - Phone:336-449-6150
Practice Address - Fax:336-449-7368
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0038371041C0700X
NCC0066291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3403407Medicaid