Provider Demographics
NPI:1184853350
Name:PHILLIPS, JUSTIN (LAC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11266 TAYLOR DRAPER LN
Mailing Address - Street 2:1422
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-2466
Mailing Address - Country:US
Mailing Address - Phone:512-673-0617
Mailing Address - Fax:
Practice Address - Street 1:911 W 38TH ST
Practice Address - Street 2:200T
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1188
Practice Address - Country:US
Practice Address - Phone:512-344-6223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01134171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist