Provider Demographics
NPI:1851504542
Name:PHILLIPS, ALSTON
Entity Type:Individual
Prefix:
First Name:ALSTON
Middle Name:
Last Name:PHILLIPS
Suffix:
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 1:810 S WEST SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4819
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12902 MAGNOLIA DRIVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:813-745-1586
Practice Address - Fax:813-745-8318
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW 45951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical