Provider Demographics
NPI:1053429852
Name:PHILLIPS, MILDRED W (LCSW)
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:W
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4903 VAN DYKE ROAD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-4813
Mailing Address - Country:US
Mailing Address - Phone:813-265-3859
Mailing Address - Fax:813-265-3966
Practice Address - Street 1:4903 VAN DYKE ROAD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-4813
Practice Address - Country:US
Practice Address - Phone:813-265-3859
Practice Address - Fax:813-265-3966
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW13701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical