Provider Demographics
NPI:1962459255
Name:PHILLIPS, BRYAN S (LCSW)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:S
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12503 HAZELWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-2913
Mailing Address - Country:US
Mailing Address - Phone:972-898-5860
Mailing Address - Fax:
Practice Address - Street 1:2323 S SHEPHERD DR STE 850
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77019-7022
Practice Address - Country:US
Practice Address - Phone:713-309-6763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX403001041C0700X
CAASW 19596104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX405325803Medicaid
TX405325801Medicaid
TX405325802Medicaid