Provider Demographics
NPI:1306995436
Name:PHILLIPS, GEORGE W (PSYD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:W
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-2250
Mailing Address - Country:US
Mailing Address - Phone:413-586-2180
Mailing Address - Fax:413-586-9800
Practice Address - Street 1:206 STATE ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-2250
Practice Address - Country:US
Practice Address - Phone:413-586-2180
Practice Address - Fax:413-586-9800
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7181103T00000X
MA202250104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0501531Medicaid
MAW06051OtherBCBSMA PROVIDER NUMBER
MA0501531Medicaid