Provider Demographics
NPI:1790036838
Name:PHIPPS, MICHELLE PETURA (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:PETURA
Last Name:PHIPPS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:PETURA
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:506 LENOX AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-1802
Mailing Address - Country:US
Mailing Address - Phone:212-939-8491
Mailing Address - Fax:
Practice Address - Street 1:506 LENOX AVENUE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1802
Practice Address - Country:US
Practice Address - Phone:212-939-8491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY076242-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker