Provider Demographics
NPI:1407841752
Name:HLA, PHUY-MAR T (DO)
Entity Type:Individual
Prefix:DR
First Name:PHUY-MAR
Middle Name:T
Last Name:HLA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 W 183RD ST
Mailing Address - Street 2:TINLEY PARK MENTAL HEALTH CENTER
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-3695
Mailing Address - Country:US
Mailing Address - Phone:708-614-4000
Mailing Address - Fax:
Practice Address - Street 1:7400 W 183RD ST
Practice Address - Street 2:TINLEY PARK MENTAL HEALTH CENTER
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3695
Practice Address - Country:US
Practice Address - Phone:708-614-4000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF74816Medicare UPIN