Provider Demographics
NPI:1265244297
Name:PHILLIPS, PUNYAWEE (LMT, MMP)
Entity type:Individual
Prefix:
First Name:PUNYAWEE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18333 ROEHAMPTON DR APT 1116
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252-5181
Mailing Address - Country:US
Mailing Address - Phone:682-368-4224
Mailing Address - Fax:
Practice Address - Street 1:2650 MIDWAY RD STE 224
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-2378
Practice Address - Country:US
Practice Address - Phone:682-368-4224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX143189225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist