Basic Information
| Provider Information | |||||||||
| NPI: | 1487744272 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | SHAUN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS, LCMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 WASHINGTON HWY | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056618715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028888320 | ||||||||
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| Practice Location | |||||||||
| Address1: | 530 WASHINGTON HWY | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056618715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028888320 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 068-0000616 | VT | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 00059497 | 01 | VT | BCBS | OTHER | 710192 | 01 | VT | MVP | OTHER | 2173851 | 01 | VT | CIGNA | OTHER | 1009840 | 05 | VT | MEDICAID |