Provider Demographics
NPI:1558502393
Name:PHILLIPS, DALE B (RPT)
Entity Type:Individual
Prefix:MRS
First Name:DALE
Middle Name:B
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 WELLER ST
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3136
Mailing Address - Country:US
Mailing Address - Phone:707-762-7678
Mailing Address - Fax:707-762-7679
Practice Address - Street 1:226 WELLER ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3136
Practice Address - Country:US
Practice Address - Phone:707-762-7678
Practice Address - Fax:707-762-7679
Is Sole Proprietor?:No
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT6185225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT6185OtherLICENSE NUMBER