Provider Demographics
NPI:1578648309
Name:PHILLIPS, TRACY ELIZABETH (LCSW, ATR)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:ELIZABETH
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LCSW, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-1311
Mailing Address - Country:US
Mailing Address - Phone:718-854-2418
Mailing Address - Fax:
Practice Address - Street 1:2795 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-5857
Practice Address - Country:US
Practice Address - Phone:718-761-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR055230-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00055230Medicaid
NYW22701OtherMAGELLEN
NY055230A37OtherHEALTH FIRST