Provider Demographics
NPI:1053834341
Name:SHANDRA PHILLIPS
Entity type:Organization
Organization Name:SHANDRA PHILLIPS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-505-4972
Mailing Address - Street 1:814 SE 18TH TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32641-9423
Mailing Address - Country:US
Mailing Address - Phone:352-278-7651
Mailing Address - Fax:
Practice Address - Street 1:205 SE 16TH AVE APT 19C
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-8635
Practice Address - Country:US
Practice Address - Phone:352-634-8068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-19
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty