Basic Information
| Provider Information | |||||||||
| NPI: | 1962624163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHELPS | ||||||||
| FirstName: | FELICIA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MSSA LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 419 GLACIERVIEW DR | ||||||||
| Address2: | |||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445091928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142889895 | ||||||||
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| Practice Location | |||||||||
| Address1: | 30 NORTHWEST AVE | ||||||||
| Address2: | |||||||||
| City: | TALLMADGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442781808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306334187 | ||||||||
| FaxNumber: | 3306334294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 02/25/2019 | ||||||||
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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 | I 0008220 | OH | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | I.0008220-SUPV | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | I.0008220-SUPV | 01 | OH | CSWMFT BOARD | OTHER |