Provider Demographics
NPI:1154813756
Name:PHILLIPS, WILLIE II (ATC)
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:
Last Name:PHILLIPS
Suffix:II
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SELWYN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28274-0001
Mailing Address - Country:US
Mailing Address - Phone:704-337-2405
Mailing Address - Fax:
Practice Address - Street 1:1900 SELWYN AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28274-0001
Practice Address - Country:US
Practice Address - Phone:704-337-2405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-37662081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCLAT-3766OtherNORTH CAROLINA BOARD OF ATHLETIC TRAINER EXAMINERS
CA2000008378OtherNATABOC