Provider Demographics
NPI:1760746952
Name:PHILLIPS, STEPHANIE G (MA, JD, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:G
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MA, JD, LMFT
Other - Prefix:MISS
Other - First Name:STEPHANIE
Other - Middle Name:E
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23 SUMMER PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-4707
Mailing Address - Country:US
Mailing Address - Phone:909-374-1827
Mailing Address - Fax:
Practice Address - Street 1:75 BISHOP ST
Practice Address - Street 2:SUITE 16
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2614
Practice Address - Country:US
Practice Address - Phone:909-374-1827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMF3166106H00000X
CAMFC35186106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist