Provider Demographics
NPI:1306451489
Name:PHILLIPS, MATTHEW J (DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 GOLFVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-1522
Mailing Address - Country:US
Mailing Address - Phone:314-757-6210
Mailing Address - Fax:
Practice Address - Street 1:15425 MANCHESTER RD STE 28
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-3077
Practice Address - Country:US
Practice Address - Phone:636-220-6969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020025098225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist