Provider Demographics
NPI:1700968419
Name:PRATHER, PHILLIP BYRON (LICSW)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:BYRON
Last Name:PRATHER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 BOBALA ROAD
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040
Mailing Address - Country:US
Mailing Address - Phone:413-536-5473
Mailing Address - Fax:413-536-2760
Practice Address - Street 1:40 BOBALA ROAD
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040
Practice Address - Country:US
Practice Address - Phone:413-536-5473
Practice Address - Fax:413-536-2760
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1029510101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
P21120Medicare UPIN