Provider Demographics
NPI:1609554252
Name:PHILLIPS, HEATHER ANN (CDCA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ANN
Other - Last Name:HERNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2737 YOUNGSTOWN RD SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-5002
Mailing Address - Country:US
Mailing Address - Phone:330-369-8022
Mailing Address - Fax:
Practice Address - Street 1:2737 YOUNGSTOWN RD SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-5002
Practice Address - Country:US
Practice Address - Phone:330-369-8022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-05
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH183341324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility