Provider Demographics
NPI:1952955205
Name:PHILLIPS, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 REYNARD DR
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-9426
Mailing Address - Country:US
Mailing Address - Phone:336-929-5763
Mailing Address - Fax:
Practice Address - Street 1:3 CENTERVIEW DRIVE
Practice Address - Street 2:HICKORY BUILDING SUITE 150
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407
Practice Address - Country:US
Practice Address - Phone:336-834-9664
Practice Address - Fax:336-834-9698
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2019-08-13
Deactivation Date:2019-07-25
Deactivation Code:
Reactivation Date:2019-08-13
Provider Licenses
StateLicense IDTaxonomies
NCP0136051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical