Provider Demographics
NPI:1720005440
Name:WILBURN, PHILLIP A (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:A
Last Name:WILBURN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3938 W 78TH CT
Mailing Address - Street 2:# 31
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-8705
Mailing Address - Country:US
Mailing Address - Phone:219-381-5648
Mailing Address - Fax:219-736-2998
Practice Address - Street 1:5241 FOUNTAIN DR
Practice Address - Street 2:SUITE G
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-5323
Practice Address - Country:US
Practice Address - Phone:219-381-5648
Practice Address - Fax:219-736-2998
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2011-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001917A1041C0700X
IL149-0011051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN627580Medicare ID - Type UnspecifiedMID#
IN000000214770Medicare UPIN