Provider Demographics
NPI:1528246253
Name:HIPPS, PHYLLIS ANN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:ANN
Last Name:HIPPS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:PHYLLIS
Other - Middle Name:ANN
Other - Last Name:HERDA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:36977 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BURNEY
Mailing Address - State:CA
Mailing Address - Zip Code:96013-4067
Mailing Address - Country:US
Mailing Address - Phone:530-335-3651
Mailing Address - Fax:
Practice Address - Street 1:36977 PARK AVE
Practice Address - Street 2:
Practice Address - City:BURNEY
Practice Address - State:CA
Practice Address - Zip Code:96013-4067
Practice Address - Country:US
Practice Address - Phone:530-335-3651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS9796001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS979600Medicaid
CALCS979600Medicaid