Basic Information
| Provider Information | |||||||||
| NPI: | 1194817775 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | LBSW RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10685 VELMA DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488389120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162252365 | ||||||||
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| Practice Location | |||||||||
| Address1: | 375 APPLE TREE DR | ||||||||
| Address2: | |||||||||
| City: | IONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488467506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165271790 | ||||||||
| FaxNumber: | 6165270538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 08/13/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6802080626 | MI | N | Behavioral Health & Social Service Providers | Social Worker | 163W00000X | 4704314040 | MI | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 1715928 | 05 | MI | MEDICAID |