Provider Demographics
NPI:1992260806
Name:PHILLIPS, SHAWN MICHAEL
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:MICHAEL
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7911 BURLWOOD LN
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-1837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4181 SW HIGH MEADOWS AVE
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-3725
Practice Address - Country:US
Practice Address - Phone:844-299-2599
Practice Address - Fax:722-247-7251
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician