Provider Demographics
NPI:1790977593
Name:PHIPPS, LARRY S (BS, CTRS)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:S
Last Name:PHIPPS
Suffix:
Gender:M
Credentials:BS, CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20018 CENTRALIA
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-1103
Mailing Address - Country:US
Mailing Address - Phone:313-532-4451
Mailing Address - Fax:
Practice Address - Street 1:30901 PALMER RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-9529
Practice Address - Country:US
Practice Address - Phone:734-367-8477
Practice Address - Fax:734-722-9524
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
23662225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
23662OtherCERTIFICATION
MI1508883299OtherWRPH