Provider Demographics
NPI:1891268561
Name:PHILLIPS, AMANDA MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-2757
Mailing Address - Country:US
Mailing Address - Phone:602-603-1538
Mailing Address - Fax:
Practice Address - Street 1:4220 N 20TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-5124
Practice Address - Country:US
Practice Address - Phone:602-889-9401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-05
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-17627101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty