Provider Demographics
NPI:1447732763
Name:PHELAN, LIBERIA
Entity type:Individual
Prefix:
First Name:LIBERIA
Middle Name:
Last Name:PHELAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 OLD WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:DIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02715-1317
Mailing Address - Country:US
Mailing Address - Phone:508-646-8093
Mailing Address - Fax:508-675-8414
Practice Address - Street 1:1135 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-2725
Practice Address - Country:US
Practice Address - Phone:508-675-8340
Practice Address - Fax:508-675-8414
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YS0200X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool