Provider Demographics
NPI:1093837601
Name:PHILLIPS, WENDY SUE (PT)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:SUE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 ELDENA RD
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-8329
Mailing Address - Country:US
Mailing Address - Phone:815-973-2825
Mailing Address - Fax:
Practice Address - Street 1:403 EAST 1ST ST
Practice Address - Street 2:KSB PHYSICAL REHAB
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-9965
Practice Address - Country:US
Practice Address - Phone:815-285-5591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist