Provider Demographics
NPI:1093469926
Name:PHILLIPS, RHONDA MARIE
Entity Type:Individual
Prefix:
First Name:RHONDA
Middle Name:MARIE
Last Name:PHILLIPS
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:PO BOX 7712
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71137-7712
Mailing Address - Country:US
Mailing Address - Phone:318-773-3520
Mailing Address - Fax:
Practice Address - Street 1:609 REDWATER RD.
Practice Address - Street 2:
Practice Address - City:WAKE VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:75501
Practice Address - Country:US
Practice Address - Phone:903-501-8032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX834685225Medicaid