Provider Demographics
NPI:1487967535
Name:PHILLIPS, THERESE (MA, RN)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MA, RN
Other - Prefix:
Other - First Name:THERESE
Other - Middle Name:
Other - Last Name:FITZPATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:49 LEMUEL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICOPEE
Mailing Address - State:MA
Mailing Address - Zip Code:01013-2511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1132 WESTFIELD ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-3878
Practice Address - Country:US
Practice Address - Phone:413-592-1980
Practice Address - Fax:413-439-0096
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MARN78288163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163W00000XNursing Service ProvidersRegistered Nurse