Provider Demographics
NPI:1720717911
Name:PHILLIPS, MICHAEL (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 SILVER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-1601
Mailing Address - Country:US
Mailing Address - Phone:302-378-3179
Mailing Address - Fax:
Practice Address - Street 1:211 SILVER LAKE RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-1601
Practice Address - Country:US
Practice Address - Phone:302-378-3179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ3-00003112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer