Provider Demographics
NPI:1366678161
Name:PHIPPS, JUDITH JOAN (MS)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:JOAN
Last Name:PHIPPS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 516
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62439
Mailing Address - Country:US
Mailing Address - Phone:618-943-3754
Mailing Address - Fax:618-943-3657
Practice Address - Street 1:RR1 BOX 277
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439
Practice Address - Country:US
Practice Address - Phone:618-943-3754
Practice Address - Fax:618-943-3754
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-105698101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL37600178008Medicaid
IL207184Medicare Oscar/Certification
IL37600178008Medicaid