Provider Demographics
NPI:1679163257
Name:PHILLIPS, DOLORES E
Entity type:Individual
Prefix:
First Name:DOLORES
Middle Name:E
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 1:1121 E MAIN ST FL 7
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45426-2411
Mailing Address - Country:US
Mailing Address - Phone:937-854-0210
Mailing Address - Fax:
Practice Address - Street 1:1121 E MAIN STREET
Practice Address - Street 2:7TH FLOOR
Practice Address - City:TROTWOOD
Practice Address - State:OH
Practice Address - Zip Code:45426-4542
Practice Address - Country:US
Practice Address - Phone:937-854-0210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1326012360Medicaid