Provider Demographics
NPI:1811378797
Name:PHILIP, PRAVEEN
Entity Type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:
Last Name:PHILIP
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 1:12501 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-8999
Mailing Address - Country:US
Mailing Address - Phone:215-410-7903
Mailing Address - Fax:
Practice Address - Street 1:12501 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-8999
Practice Address - Country:US
Practice Address - Phone:215-410-7903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116956225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist