Provider Demographics
NPI:1801393103
Name:PHILLIPS, ALBERT LEON JR
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:LEON
Last Name:PHILLIPS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2741 GLENVALLEY DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-4207
Mailing Address - Country:US
Mailing Address - Phone:404-840-4896
Mailing Address - Fax:
Practice Address - Street 1:2741 GLENVALLEY DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-4207
Practice Address - Country:US
Practice Address - Phone:404-840-4896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW008225104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty