Provider Demographics
NPI:1790149664
Name:PHILLIPS, TAYLOR
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
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 1:251 JOHNSTON ST SE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-2515
Mailing Address - Country:US
Mailing Address - Phone:256-340-9708
Mailing Address - Fax:256-340-9624
Practice Address - Street 1:674 OLLIE AVE
Practice Address - Street 2:
Practice Address - City:CLANTON
Practice Address - State:AL
Practice Address - Zip Code:35045-2246
Practice Address - Country:US
Practice Address - Phone:205-280-1100
Practice Address - Fax:205-280-1575
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH7904225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529917620Medicaid
AL1003819608OtherGOUP NPI
AL529917620Medicaid