Provider Demographics
NPI:1104914126
Name:PHILLIPS, MINDI (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MINDI
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:MINDI
Other - Middle Name:
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:90 HOWARD DR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-8138
Mailing Address - Country:US
Mailing Address - Phone:502-633-1007
Mailing Address - Fax:502-437-0624
Practice Address - Street 1:90 HOWARD DR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-8138
Practice Address - Country:US
Practice Address - Phone:502-633-1007
Practice Address - Fax:502-437-0624
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8902235Z00000X
KY140964235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891230100Medicaid