Provider Demographics
NPI:1639327877
Name:PHILLIPS, DENNIS RAY (LCSW)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:RAY
Last Name:PHILLIPS
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 1:5656 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-9641
Mailing Address - Country:US
Mailing Address - Phone:903-589-9000
Mailing Address - Fax:903-589-3443
Practice Address - Street 1:5656 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-9641
Practice Address - Country:US
Practice Address - Phone:903-589-9000
Practice Address - Fax:903-589-3443
Is Sole Proprietor?:No
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82683WMedicare UPIN