Provider Demographics
NPI:1174135669
Name:PHILLIPS, DIANE ELIZABETH (LCSW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:ELIZABETH
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 1:6931 PIN OAK CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-3962
Mailing Address - Country:US
Mailing Address - Phone:518-859-8758
Mailing Address - Fax:
Practice Address - Street 1:1250 SE MAYNARD RD STE 204
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-6947
Practice Address - Country:US
Practice Address - Phone:919-948-7718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0117651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC011765Medicaid