Provider Demographics
NPI:1962434647
Name:PHILLIPS, MARIANNE (LCMHC, LADC)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LCMHC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 FLYNN AVE
Mailing Address - Street 2:3J
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5429
Mailing Address - Country:US
Mailing Address - Phone:802-488-6900
Mailing Address - Fax:802-488-6919
Practice Address - Street 1:855 PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4924
Practice Address - Country:US
Practice Address - Phone:802-488-6103
Practice Address - Fax:802-488-6919
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000189101YA0400X
VT068-0000617101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010732Medicaid