Provider Demographics
NPI:1134609670
Name:PHILLIPS, MARSHA FAYE (LICENSED SOCIAL WORK)
Entity type:Individual
Prefix:MISS
First Name:MARSHA
Middle Name:FAYE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LICENSED SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 492
Mailing Address - Street 2:
Mailing Address - City:KIMBALL
Mailing Address - State:WV
Mailing Address - Zip Code:24853-0492
Mailing Address - Country:US
Mailing Address - Phone:304-928-5678
Mailing Address - Fax:
Practice Address - Street 1:52 TOMMY ST
Practice Address - Street 2:
Practice Address - City:KIMBALL
Practice Address - State:WV
Practice Address - Zip Code:24853-2485
Practice Address - Country:US
Practice Address - Phone:304-928-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAP009409553104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty