Provider Demographics
NPI:1487976510
Name:PHILLIPS, CHARESE AMILLE
Entity type:Individual
Prefix:MRS
First Name:CHARESE
Middle Name:AMILLE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARESE
Other - Middle Name:AMILLE
Other - Last Name:MCINNISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1465 30TH ST
Mailing Address - Street 2:STE. K
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-3497
Mailing Address - Country:US
Mailing Address - Phone:619-428-1000
Mailing Address - Fax:619-428-1091
Practice Address - Street 1:1465 30TH ST
Practice Address - Street 2:STE. K
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-3497
Practice Address - Country:US
Practice Address - Phone:619-428-1000
Practice Address - Fax:619-428-1091
Is Sole Proprietor?:No
Enumeration Date:2010-02-16
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health