Provider Demographics
NPI: | 1467902809 |
---|---|
Name: | PHILLIPS, DEREK (PSYD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | DEREK |
Middle Name: | |
Last Name: | PHILLIPS |
Suffix: | |
Gender: | M |
Credentials: | PSYD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 372 |
Mailing Address - Street 2: | |
Mailing Address - City: | MATTOON |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 61938-0372 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 217-682-8128 |
Mailing Address - Fax: | 217-258-2216 |
Practice Address - Street 1: | 1000 HEALTH CENTER DR STE 107 |
Practice Address - Street 2: | |
Practice Address - City: | MATTOON |
Practice Address - State: | IL |
Practice Address - Zip Code: | 61938-4644 |
Practice Address - Country: | US |
Practice Address - Phone: | 217-258-4096 |
Practice Address - Fax: | 217-238-5485 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2016-10-10 |
Last Update Date: | 2024-01-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 071.009513 | 103T00000X |
IL | 074.000012 | 103TP0016X, 103TP0016X |
IL | 071009513 | 103TC0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 103TP0016X | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) |
No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | |
No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |