Provider Demographics
NPI:1629168067
Name:PHILLIPS, LINDA ELAINE (MED LICENSED PROFESS)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:ELAINE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MED LICENSED PROFESS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 SALEM ROAD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034
Mailing Address - Country:US
Mailing Address - Phone:501-336-8300
Mailing Address - Fax:501-329-3572
Practice Address - Street 1:110 SKYLINE DRIVE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801
Practice Address - Country:US
Practice Address - Phone:479-968-1298
Practice Address - Fax:479-968-6053
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP8906008101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health