Provider Demographics
NPI:1316490626
Name:PHILLIPS, DIANE SHARLEAN
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:SHARLEAN
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 1:1553 N WALLER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-1134
Mailing Address - Country:US
Mailing Address - Phone:708-298-2573
Mailing Address - Fax:
Practice Address - Street 1:1553 N WALLER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-1134
Practice Address - Country:US
Practice Address - Phone:708-298-2573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist