Provider Demographics
NPI:1457124885
Name:STATON, PHILLIP TRENT II
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:TRENT
Last Name:STATON
Suffix:II
Gender:M
Credentials:
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 14608
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27415-4608
Mailing Address - Country:US
Mailing Address - Phone:336-709-5447
Mailing Address - Fax:
Practice Address - Street 1:604 MEADOW ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6600
Practice Address - Country:US
Practice Address - Phone:800-632-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA19209101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health