Provider Demographics
NPI:1639109184
Name:PEARSON, PHYLLIS MAE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:MAE
Last Name:PEARSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:PHYLLIS
Other - Middle Name:MAE
Other - Last Name:MANNEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4949 CALLE ROBLEDA
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-2471
Mailing Address - Country:US
Mailing Address - Phone:818-991-0622
Mailing Address - Fax:
Practice Address - Street 1:333 N LANTANA
Practice Address - Street 2:SUITE 269
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010
Practice Address - Country:US
Practice Address - Phone:818-991-0622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS79401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical