Provider Demographics
NPI:1619618097
Name:PHILLIPS, CHRISTIN C
Entity Type:Individual
Prefix:
First Name:CHRISTIN
Middle Name:C
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 DONAGHEY AVE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-5143
Mailing Address - Country:US
Mailing Address - Phone:501-733-0057
Mailing Address - Fax:
Practice Address - Street 1:207 FRED RAINS DR
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-5457
Practice Address - Country:US
Practice Address - Phone:501-834-0217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR373H00000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1124083118OtherNPI
AR280916795Medicaid