Provider Demographics
NPI:1144394529
Name:TROTTER, PHYLLIS J (AU D/ CCC-A)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:J
Last Name:TROTTER
Suffix:
Gender:F
Credentials:AU D/ CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 E GRANDE BLVD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3982
Mailing Address - Country:US
Mailing Address - Phone:903-592-5601
Mailing Address - Fax:903-595-3304
Practice Address - Street 1:1136 E GRANDE BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3982
Practice Address - Country:US
Practice Address - Phone:903-592-5601
Practice Address - Fax:903-595-3304
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3575231H00000X
TX80550231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX322324001Medicaid
TX80859AOtherBCBS BLUE
ND54903Medicaid
TX75-2616977-009OtherTRICARE
TXP01226413OtherMEDICARE RAIL ROAD
TXP01226413OtherMEDICARE RAIL ROAD
TX75-2616977-009OtherTRICARE
TX322324001Medicaid