Provider Demographics
NPI:1780168872
Name:PHILLIPS, CHRISTA NICOLE (MHP)
Entity type:Individual
Prefix:
First Name:CHRISTA
Middle Name:NICOLE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 W SAINT ANTHONY AVE APT A
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2326
Mailing Address - Country:US
Mailing Address - Phone:217-329-9868
Mailing Address - Fax:
Practice Address - Street 1:1901 S 4TH ST STE 213
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-4188
Practice Address - Country:US
Practice Address - Phone:217-347-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health