Provider Demographics
NPI:1164609053
Name:PHILLIPS, PAULINE S (MT)
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:S
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4114 40TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-3445
Mailing Address - Country:US
Mailing Address - Phone:612-250-5232
Mailing Address - Fax:
Practice Address - Street 1:4114 40TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-3445
Practice Address - Country:US
Practice Address - Phone:612-250-5232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist