Provider Demographics
NPI:1184753667
Name:PHILLIPS, MARIA PA (LAC CA)
Entity type:Individual
Prefix:MS
First Name:MARIA
Middle Name:PA
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LAC CA
Other - Prefix:MS
Other - First Name:MARIA
Other - Middle Name:PA
Other - Last Name:PHILLIPS BLACKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC CA
Mailing Address - Street 1:39 LORI ST
Mailing Address - Street 2:
Mailing Address - City:MONROE TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-8644
Mailing Address - Country:US
Mailing Address - Phone:732-416-9151
Mailing Address - Fax:
Practice Address - Street 1:39 LORI ST
Practice Address - Street 2:
Practice Address - City:MONROE TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08831-8644
Practice Address - Country:US
Practice Address - Phone:732-416-9151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002811171100000X
NJ25MZ00039600171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist