Provider Demographics
NPI:1053701276
Name:PHILLIPS, HALLENA
Entity type:Individual
Prefix:
First Name:HALLENA
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 1:216 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CLARINDA
Mailing Address - State:IA
Mailing Address - Zip Code:51632-2509
Mailing Address - Country:US
Mailing Address - Phone:712-542-2388
Mailing Address - Fax:712-542-2984
Practice Address - Street 1:216 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CLARINDA
Practice Address - State:IA
Practice Address - Zip Code:51632-2509
Practice Address - Country:US
Practice Address - Phone:712-542-2388
Practice Address - Fax:712-542-2984
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001413104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker