Provider Demographics
NPI:1427547074
Name:PHILLIPS, REKUETA LASHON (RBT-17-34179)
Entity Type:Individual
Prefix:
First Name:REKUETA
Middle Name:LASHON
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RBT-17-34179
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 FACEL VEGA DR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6487
Mailing Address - Country:US
Mailing Address - Phone:815-995-1428
Mailing Address - Fax:
Practice Address - Street 1:2904 FACEL VEGA DR
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6487
Practice Address - Country:US
Practice Address - Phone:815-995-1428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-17-34179106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty