Basic Information
Provider Information
NPI: 1003002171
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BRINCEFIELD PHILLIPS
FirstName: LIZA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MA, CCC-SLP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: PHILLIPS
OtherFirstName: LIZA
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: MA CFY-SLP
OtherLastNameType: 2
Mailing Information
Address1: 185 CHARLOIS BLVD
Address2:  
City: WINSTON SALEM
State: NC
PostalCode: 271031521
CountryCode: US
TelephoneNumber: 3367250222
FaxNumber: 3357250454
Practice Location
Address1: 185 CHARLOIS BLVD
Address2:  
City: WINSTON SALEM
State: NC
PostalCode: 271031521
CountryCode: US
TelephoneNumber: 3367250222
FaxNumber: 3367250454
Other Information
ProviderEnumerationDate: 09/21/2007
LastUpdateDate: 06/17/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
235Z00000X NCY Speech, Language and Hearing Service ProvidersSpeech-Language Pathologist 

No ID Information.


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