Provider Demographics
NPI:1134438856
Name:PHILLIPS, TONYA CHARISE (LCSW-C,LCADC)
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:CHARISE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LCSW-C,LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2464 85TH MEDICAL BN AVENUE
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN PROVING GROUND
Mailing Address - State:MD
Mailing Address - Zip Code:20755
Mailing Address - Country:US
Mailing Address - Phone:301-677-7188
Mailing Address - Fax:301-677-5416
Practice Address - Street 1:2464 85TH MEDICAL BN AVENUE
Practice Address - Street 2:
Practice Address - City:ABERDEEN PROVING GROUND
Practice Address - State:MD
Practice Address - Zip Code:20755
Practice Address - Country:US
Practice Address - Phone:301-677-7188
Practice Address - Fax:301-677-5416
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA1814101YA0400X
MD143641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)