Provider Demographics
NPI:1487153094
Name:PHILLIPS, LOLITA PATRICE (SAC-IT)
Entity type:Individual
Prefix:
First Name:LOLITA
Middle Name:PATRICE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2961 YARMOUTH GREENWAY DR STE 2
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-5809
Mailing Address - Country:US
Mailing Address - Phone:608-218-5785
Mailing Address - Fax:
Practice Address - Street 1:2961 YARMOUTH GREENWAY DR STE 2
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-5809
Practice Address - Country:US
Practice Address - Phone:608-218-5785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18482-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)