Provider Demographics
NPI:1932373677
Name:WEST, PHILLIP CHARLES (ADDICTION COUNSELOR)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:CHARLES
Last Name:WEST
Suffix:
Gender:M
Credentials:ADDICTION COUNSELOR
Other - Prefix:
Other - First Name:PHILLIP
Other - Middle Name:
Other - Last Name:WEST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CERTIFIED
Mailing Address - Street 1:1800 BETHUNE
Mailing Address - Street 2:APT.104
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206
Mailing Address - Country:US
Mailing Address - Phone:313-778-2696
Mailing Address - Fax:
Practice Address - Street 1:1800 W BETHUNE ST APT 104
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48206-2674
Practice Address - Country:US
Practice Address - Phone:313-778-2696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI10082101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI141928000Medicaid