Provider Demographics
NPI:1679271217
Name:PHILLIPS, STEPHEN WESLEY
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:WESLEY
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 OLD PEACHLAND RD
Mailing Address - Street 2:
Mailing Address - City:MARSHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28103-7533
Mailing Address - Country:US
Mailing Address - Phone:201-848-5144
Mailing Address - Fax:
Practice Address - Street 1:4123 KUYKENDALL RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-4449
Practice Address - Country:US
Practice Address - Phone:704-708-9931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15138224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant