Provider Demographics
NPI:1487978169
Name:PHILLIPS, DIANE K (LCSW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:K
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 1:1032 CROSSWINDS CT
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-4836
Mailing Address - Country:US
Mailing Address - Phone:636-332-8310
Mailing Address - Fax:
Practice Address - Street 1:2615 EDWARDS ST
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-3915
Practice Address - Country:US
Practice Address - Phone:618-462-2331
Practice Address - Fax:318-462-2504
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090279471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical