Basic Information
| Provider Information | |||||||||
| NPI: | 1952955205 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | SANDRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1507 REYNARD DR | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272849426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369295763 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3 CENTERVIEW DRIVE | ||||||||
| Address2: | HICKORY BUILDING SUITE 150 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368349664 | ||||||||
| FaxNumber: | 3368349698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2019 | ||||||||
| LastUpdateDate: | 08/13/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/25/2019 | ||||||||
| NPIReactivationDate: | 08/13/2019 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P013605 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.