Provider Demographics
NPI:1871841197
Name:PHILLIPS, REBECCA (MA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 W MIDWAY RD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34981-4823
Mailing Address - Country:US
Mailing Address - Phone:772-380-2247
Mailing Address - Fax:
Practice Address - Street 1:2806 S US HIGHWAY 1 STE C7
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-8109
Practice Address - Country:US
Practice Address - Phone:772-380-2247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH10238101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health