Provider Demographics
NPI:1053941690
Name:VENTOCILLA, PHYLLIS RITA (LMSW)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:RITA
Last Name:VENTOCILLA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15686 RIVER SIDE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9243
Mailing Address - Country:US
Mailing Address - Phone:231-728-3442
Mailing Address - Fax:
Practice Address - Street 1:1050 W WESTERN AVE STE 400
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-1666
Practice Address - Country:US
Practice Address - Phone:231-728-3442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801061129104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker