Provider Demographics
NPI:1568249084
Name:RICHARD, PHILLIP (PT, DPT)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:RICHARD
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:
Practice Address - Street 1:225 N MOONLIGHT RD
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:KS
Practice Address - Zip Code:66030-1928
Practice Address - Country:US
Practice Address - Phone:913-856-7927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-07458225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist