Provider Demographics
NPI:1861817421
Name:PHILLIPS, CRAIG ROBERT
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:ROBERT
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 1:414 DOCTORS CT
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-2065
Mailing Address - Country:US
Mailing Address - Phone:920-456-2030
Mailing Address - Fax:
Practice Address - Street 1:414 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-2065
Practice Address - Country:US
Practice Address - Phone:920-456-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-19
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2041-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1861817421Medicaid