Provider Demographics
NPI:1285871939
Name:PHILLIPS, ANNIE LANE (LPC, PHD)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:LANE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LPC, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 LINKHORN DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-3920
Mailing Address - Country:US
Mailing Address - Phone:757-651-3001
Mailing Address - Fax:
Practice Address - Street 1:817 LINKHORN DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-3920
Practice Address - Country:US
Practice Address - Phone:757-651-3001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-16
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004521101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007770359Medicaid
VA680000167Medicare PIN
VA007770359Medicaid