Provider Demographics
NPI:1346727872
Name:PHILLIPS, TADIE REPOLL
Entity Type:Individual
Prefix:
First Name:TADIE
Middle Name:REPOLL
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 MARIETTA DR W
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36618-2343
Mailing Address - Country:US
Mailing Address - Phone:251-656-5207
Mailing Address - Fax:
Practice Address - Street 1:1213 MARIETTA DR W
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36618-2343
Practice Address - Country:US
Practice Address - Phone:251-656-5207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer