Provider Demographics
NPI:1962815472
Name:PHILLIPS, ALBERT (LGSW)
Entity Type:Individual
Prefix:MR
First Name:ALBERT
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4604 SUNBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-3326
Mailing Address - Country:US
Mailing Address - Phone:443-415-5384
Mailing Address - Fax:
Practice Address - Street 1:4604 SUNBROOK AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21206-3326
Practice Address - Country:US
Practice Address - Phone:443-415-5384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDG11381101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health