Provider Demographics
NPI:1629534896
Name:PHILLIPS, MICHAEL C (LPC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 DURAND FALLS DRIVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030
Mailing Address - Country:US
Mailing Address - Phone:404-274-4688
Mailing Address - Fax:
Practice Address - Street 1:4015 S COBB DR SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6303
Practice Address - Country:US
Practice Address - Phone:404-274-4688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010756101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional