Provider Demographics
NPI:1326070467
Name:PHILIPP, EUGENE P JR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:P
Last Name:PHILIPP
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 FRONT STREET
Mailing Address - Street 2:SUITE 3D
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-1667
Mailing Address - Country:US
Mailing Address - Phone:920-885-2780
Mailing Address - Fax:920-885-2788
Practice Address - Street 1:200 FRONT STREET
Practice Address - Street 2:SUITE 3D
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-1667
Practice Address - Country:US
Practice Address - Phone:920-885-2780
Practice Address - Fax:920-885-2788
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1628057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39092200Medicaid