Provider Demographics
NPI:1912568072
Name:PHILLIPS, ALECIA DIEDRE
Entity Type:Individual
Prefix:
First Name:ALECIA
Middle Name:DIEDRE
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 1:2975 GRANDEVILLE CIR APT 217
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-6083
Mailing Address - Country:US
Mailing Address - Phone:862-210-0203
Mailing Address - Fax:
Practice Address - Street 1:8617 E COLONIAL DR STE 1100
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-3919
Practice Address - Country:US
Practice Address - Phone:407-895-0801
Practice Address - Fax:407-930-2569
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRBT-17-37144106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty