Provider Demographics
NPI:1336974211
Name:AMES PHILLIPS, ANNA MARY
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:MARY
Last Name:AMES PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1779 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-5243
Mailing Address - Country:US
Mailing Address - Phone:612-280-9168
Mailing Address - Fax:651-330-8718
Practice Address - Street 1:2565 HAMLINE AVE N STE A
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-3181
Practice Address - Country:US
Practice Address - Phone:763-515-8893
Practice Address - Fax:651-330-8718
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN279441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical