Provider Demographics
NPI:1750806691
Name:PHILLIPS, AUDREY (BA, CAC-P)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:BA, CAC-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 WILTSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:LONGS
Mailing Address - State:SC
Mailing Address - Zip Code:29568-8872
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2404 WISE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-5521
Practice Address - Country:US
Practice Address - Phone:843-488-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-12
Last Update Date:2017-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)