Provider Demographics
NPI:1336157247
Name:PHILLIPS, NANCY JEAN (LCSW-R)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:JEAN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11302 MILL ST
Mailing Address - Street 2:
Mailing Address - City:LEONARDSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13364
Mailing Address - Country:US
Mailing Address - Phone:315-855-4623
Mailing Address - Fax:607-334-5779
Practice Address - Street 1:3 OHARA DR
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815-2046
Practice Address - Country:US
Practice Address - Phone:607-334-8244
Practice Address - Fax:607-336-5779
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY074101-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11857016OtherCAQH