Provider Demographics
NPI:1922312776
Name:PHILLIPS, SANDRA E (LCSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:E
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 SW NYE ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-3821
Mailing Address - Country:US
Mailing Address - Phone:208-467-4889
Mailing Address - Fax:541-265-0601
Practice Address - Street 1:51 SW LEE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3823
Practice Address - Country:US
Practice Address - Phone:208-467-4889
Practice Address - Fax:208-467-4499
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL6950101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500768958Medicaid