Provider Demographics
NPI:1316569726
Name:PHIPPS, JUDAH L (PTA)
Entity Type:Individual
Prefix:
First Name:JUDAH
Middle Name:L
Last Name:PHIPPS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7879 S 700 W
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:47993-8264
Mailing Address - Country:US
Mailing Address - Phone:765-426-3768
Mailing Address - Fax:
Practice Address - Street 1:407 E MARKET ST STE 102
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-1852
Practice Address - Country:US
Practice Address - Phone:765-362-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005552A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN06005552AOtherSTATE LICENSE