Provider Demographics
NPI:1740900612
Name:PHILLIPS, DEMETRIA D
Entity type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:D
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10144 WILD HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77088-2150
Mailing Address - Country:US
Mailing Address - Phone:337-570-0712
Mailing Address - Fax:
Practice Address - Street 1:5215 FM 1960 RD W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77069-4414
Practice Address - Country:US
Practice Address - Phone:337-570-0712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1602217405300000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No405300000XOther Service ProvidersPrevention Professional