Provider Demographics
NPI:1518231570
Name:PHILLIPS, LUKE WILLIAM
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:WILLIAM
Last Name:PHILLIPS
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 1:309 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-1921
Mailing Address - Country:US
Mailing Address - Phone:573-380-9051
Mailing Address - Fax:
Practice Address - Street 1:806 S KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5919
Practice Address - Country:US
Practice Address - Phone:573-471-0110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008022311225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant