Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TB0200X | Cognitive & Behavioral Psychologist | 071.010543 | IL |
NPI | 1124545389 |
---|---|
Provider Name | David Phillips |
First Address | Mchenry, IL 60050-5449 |
Second Address | Mchenry, IL 60050-5449 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/08/2017 |
Last Update Date | 08/11/2021 |