Provider Demographics
NPI:1093708208
Name:PHILLIPS, ROBERT J DEAN (MS,LCPC,NCC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:J DEAN
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MS,LCPC,NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-3032
Mailing Address - Country:US
Mailing Address - Phone:217-347-7179
Mailing Address - Fax:
Practice Address - Street 1:1200 N 4TH ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-3032
Practice Address - Country:US
Practice Address - Phone:217-347-7179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005312101YP2500X
IN39002212A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180-005312OtherLCPC
IL370912882Medicaid
202794OtherNATIONAL CERTIFICATION
IN39002212AOtherINDIANA PROFESSIONAL LICENSING