Provider Demographics
NPI:1649344995
Name:PHILLIPS, TRICIA L (LPC, NCC, CCJP)
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:L
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LPC, NCC, CCJP
Other - Prefix:
Other - First Name:TRICIA
Other - Middle Name:L
Other - Last Name:BOLERJACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11825 PRIVATE DRIVE 5136
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-5909
Mailing Address - Country:US
Mailing Address - Phone:573-647-1746
Mailing Address - Fax:
Practice Address - Street 1:13160 COUNTY RD. 3610
Practice Address - Street 2:
Practice Address - City:ST. JAMES
Practice Address - State:MO
Practice Address - Zip Code:65559-9989
Practice Address - Country:US
Practice Address - Phone:573-265-3251
Practice Address - Fax:573-265-8363
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005038745101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor