Provider Demographics
NPI:1265956098
Name:EMERSON, PHILLIP H (LISW)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:H
Last Name:EMERSON
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14701 DETROIT AVE
Mailing Address - Street 2:STE 775
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4120
Mailing Address - Country:US
Mailing Address - Phone:216-315-3570
Mailing Address - Fax:
Practice Address - Street 1:14701 DETROIT AVE STE 775
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4120
Practice Address - Country:US
Practice Address - Phone:216-315-3570
Practice Address - Fax:216-228-1610
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.20024881041C0700X
OH1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0311599Medicaid
OHI.2002488OtherOHIO LISW LICENSE NUMBER