Provider Demographics
NPI:1699146266
Name:PHILLIPS, MARY JOHNSON
Entity type:Individual
Prefix:MS
First Name:MARY JOHNSON
Middle Name:
Last Name: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 1:1117 WILLOUGHBY AVE
Mailing Address - Street 2:APT. 3R
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-2745
Mailing Address - Country:US
Mailing Address - Phone:917-929-3577
Mailing Address - Fax:
Practice Address - Street 1:1117 WILLOUGHBY AVE
Practice Address - Street 2:APT. 3R
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-2745
Practice Address - Country:US
Practice Address - Phone:917-929-3755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7631759251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management