Provider Demographics
NPI:1407075468
Name:HAWK, PHILLIP G
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:G
Last Name:HAWK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-1762
Mailing Address - Country:US
Mailing Address - Phone:708-503-1434
Mailing Address - Fax:
Practice Address - Street 1:3033 W JEFFERSON ST
Practice Address - Street 2:SUITE 215
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5261
Practice Address - Country:US
Practice Address - Phone:815-773-0772
Practice Address - Fax:815-773-0771
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional