Provider Demographics
NPI:1790538106
Name:PHILLIPS, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
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 1:308 BLUEGRASS LN
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-7811
Mailing Address - Country:US
Mailing Address - Phone:832-630-8381
Mailing Address - Fax:
Practice Address - Street 1:308 BLUEGRASS LN
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76039-7811
Practice Address - Country:US
Practice Address - Phone:832-630-8381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician