Provider Demographics
NPI:1891078762
Name:PHILLIPS, MEGAN (OT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:GORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 E PULASKI HWY
Practice Address - Street 2:SUITE B
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-6457
Practice Address - Country:US
Practice Address - Phone:410-398-1690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEU1-0001270225X00000X
MD07038225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE231349Y0XMedicare PIN