Provider Demographics
NPI:1639360126
Name:PHILLIPS, RUSTY LANE (LCSW)
Entity Type:Individual
Prefix:
First Name:RUSTY
Middle Name:LANE
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 1:206 RUE GAMBETTA
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70507-5335
Mailing Address - Country:US
Mailing Address - Phone:337-592-0185
Mailing Address - Fax:337-824-4315
Practice Address - Street 1:206 RUE GAMBETTA
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70507-5335
Practice Address - Country:US
Practice Address - Phone:337-592-0185
Practice Address - Fax:337-824-4315
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA72851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical