Provider Demographics
NPI:1558858282
Name:HAWKINS, PHYLLIS ROSE (LMBT)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:ROSE
Last Name:HAWKINS
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 VAN BUREN DR
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-9418
Mailing Address - Country:US
Mailing Address - Phone:910-479-4306
Mailing Address - Fax:
Practice Address - Street 1:207 VAN BUREN DR
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-9418
Practice Address - Country:US
Practice Address - Phone:910-479-4306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14015225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist