Provider Demographics
NPI:1235526245
Name:PHILLIPS, TERRY JR (BS)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:PHILLIPS
Suffix:JR
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 BURLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WESTERN SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60558-1516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17800 KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2029
Practice Address - Country:US
Practice Address - Phone:708-213-3825
Practice Address - Fax:708-213-0132
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
IL070.023344225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator