Provider Demographics
NPI:1588751168
Name:PHILLIPS, MARISA JON (LPC/NCC)
Entity type:Individual
Prefix:MS
First Name:MARISA
Middle Name:JON
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LPC/NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 ASHLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3659
Mailing Address - Country:US
Mailing Address - Phone:936-637-3300
Mailing Address - Fax:936-637-1614
Practice Address - Street 1:3402 DANIEL MCCALL DR STE 21
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-7191
Practice Address - Country:US
Practice Address - Phone:936-637-3300
Practice Address - Fax:936-637-1614
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14106101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1426504Medicaid
TX83663LOtherBLUE CROSS/BLUE SHIELD