Provider Demographics
NPI:1609224237
Name:PHILLIP, ROBERTA (HIS)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:PHILLIP
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NATIONAL HWY
Mailing Address - Street 2:
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21502-7335
Mailing Address - Country:US
Mailing Address - Phone:301-729-2248
Mailing Address - Fax:877-402-2669
Practice Address - Street 1:700 NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21502-7335
Practice Address - Country:US
Practice Address - Phone:301-729-2248
Practice Address - Fax:877-402-2669
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02529237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist