Provider Demographics
NPI:1730314964
Name:PHILLIPS, NICOLE C (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:C
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:7511 LEMONT RD
Practice Address - Street 2:SUITE 204
Practice Address - City:DARIEN
Practice Address - State:IL
Practice Address - Zip Code:60561-4394
Practice Address - Country:US
Practice Address - Phone:630-985-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL07-0017097225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00790089OtherMEDICARE RR
IL212622006Medicare PIN
ILP00790089OtherMEDICARE RR
IL212623006Medicare PIN
IL214708009Medicare PIN
IL212989008Medicare PIN
IL202845046Medicare PIN