Provider Demographics
NPI:1720223019
Name:PHILLIPS, MARK WELDON (LSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WELDON
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 OREGONIA RD FL 2
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-3903
Mailing Address - Country:US
Mailing Address - Phone:513-695-2411
Mailing Address - Fax:513-695-2309
Practice Address - Street 1:212 COOK RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-9600
Practice Address - Country:US
Practice Address - Phone:513-695-1357
Practice Address - Fax:513-695-1831
Is Sole Proprietor?:No
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS-201151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical