Provider Demographics
NPI:1851982854
Name:PHILLIPS, KEETON
Entity Type:Individual
Prefix:
First Name:KEETON
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 W FARWELL AVE APT 2N
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-3633
Mailing Address - Country:US
Mailing Address - Phone:812-204-3469
Mailing Address - Fax:
Practice Address - Street 1:4846 N CLARK ST STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-7925
Practice Address - Country:US
Practice Address - Phone:312-574-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.104928104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker