Provider Demographics
NPI:1689167165
Name:PHILLIPS, LINDA MARIE (LCDC III)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:MARIE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11821 SR 160
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:OH
Mailing Address - Zip Code:45686
Mailing Address - Country:US
Mailing Address - Phone:740-245-3051
Mailing Address - Fax:
Practice Address - Street 1:11821 SR 160
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:OH
Practice Address - Zip Code:45686
Practice Address - Country:US
Practice Address - Phone:174-057-7167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDC111.161683101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH27-4752905Medicaid