Provider Demographics
NPI:1144278532
Name:PHILLIPS, DAWN (MPT)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 IAA DR APT 5
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-2265
Mailing Address - Country:US
Mailing Address - Phone:309-453-7542
Mailing Address - Fax:
Practice Address - Street 1:215 W LOCUST ST
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:IL
Practice Address - Zip Code:61739-1550
Practice Address - Country:US
Practice Address - Phone:815-692-3941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-014912225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070-014912OtherIL LICENSE NO