Provider Demographics
NPI:1457983108
Name:PHILLIPS, ANDREW RYAN
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:RYAN
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 S HUNTLEY ST
Mailing Address - Street 2:
Mailing Address - City:MAPLE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60151-7618
Mailing Address - Country:US
Mailing Address - Phone:630-885-8603
Mailing Address - Fax:
Practice Address - Street 1:429 S HUNTLEY ST
Practice Address - Street 2:
Practice Address - City:MAPLE PARK
Practice Address - State:IL
Practice Address - Zip Code:60151-7618
Practice Address - Country:US
Practice Address - Phone:630-885-8603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0266911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL474579189001Medicaid