Basic Information
| Provider Information | |||||||||
| NPI: | 1578648309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, ATR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 811 GREENWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112181311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188542418 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2795 RICHMOND AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103145857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187619800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | R055230-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 00055230 | 05 | NY | MEDICAID | W22701 | 01 | NY | MAGELLEN | OTHER | 055230A37 | 01 | NY | HEALTH FIRST | OTHER |