Provider Demographics
NPI:1891272779
Name:PHILLIPS, REQUITA CHEYENNE
Entity Type:Individual
Prefix:
First Name:REQUITA
Middle Name:CHEYENNE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4629 AICHOLTZ RD STE 2
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45244-1560
Mailing Address - Country:US
Mailing Address - Phone:513-752-1555
Mailing Address - Fax:
Practice Address - Street 1:4633 AICHOLTZ RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45244-1447
Practice Address - Country:US
Practice Address - Phone:513-752-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH167022101YA0400X
171M00000X
OHC.2103248101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator