Provider Demographics
NPI:1992158729
Name:PHILLIPS, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
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 1:142 W YORK ST
Mailing Address - Street 2:STE 805
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-2015
Mailing Address - Country:US
Mailing Address - Phone:757-622-2114
Mailing Address - Fax:
Practice Address - Street 1:142 W YORK ST
Practice Address - Street 2:STE 805
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-2015
Practice Address - Country:US
Practice Address - Phone:757-622-2114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-17
Last Update Date:2016-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006686101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional