Provider Demographics
NPI:1275305732
Name:PHILLIPS, NICOLE T (LMT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:T
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6876 W WILLIAMS DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-5227
Mailing Address - Country:US
Mailing Address - Phone:623-414-1281
Mailing Address - Fax:
Practice Address - Street 1:13610 N SCOTTSDALE RD STE 132
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-4037
Practice Address - Country:US
Practice Address - Phone:623-414-1281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-24981225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist