Provider Demographics
NPI:1366996498
Name:ANTHONY, PHILLIP DWIGHT (LPC, LCDC)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:DWIGHT
Last Name:ANTHONY
Suffix:
Gender:M
Credentials:LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 CAP ROCK LN
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-8819
Mailing Address - Country:US
Mailing Address - Phone:214-206-6912
Mailing Address - Fax:
Practice Address - Street 1:4549 S WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-1015
Practice Address - Country:US
Practice Address - Phone:214-206-6912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72908101Y00000X, 101YM0800X, 101YP2500X, 103K00000X
TX8205101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst