Provider Demographics
NPI:1366468050
Name:PHILLIPS, GEORGIA M (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:M
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-1432
Mailing Address - Country:US
Mailing Address - Phone:956-982-8578
Mailing Address - Fax:956-982-8741
Practice Address - Street 1:2424 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78521-1432
Practice Address - Country:US
Practice Address - Phone:956-982-8578
Practice Address - Fax:956-982-8741
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10313235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161372101Medicaid