Provider Demographics
NPI:1356936728
Name:PHILLIPS, JUSTINE (ATC)
Entity type:Individual
Prefix:MRS
First Name:JUSTINE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6731 ALAMO WAY
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-5807
Mailing Address - Country:US
Mailing Address - Phone:714-504-3478
Mailing Address - Fax:
Practice Address - Street 1:6731 ALAMO WAY
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-5807
Practice Address - Country:US
Practice Address - Phone:714-504-3478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-07
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2000040731225400000X
CABOC3817202255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner