Provider Demographics
NPI:1487882122
Name:HALLIDAY, PHILLIP MCKENZIE
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:MCKENZIE
Last Name:HALLIDAY
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 1:607 COUNTRY CLUB APTS
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:PA
Mailing Address - Zip Code:18612-9191
Mailing Address - Country:US
Mailing Address - Phone:570-956-2703
Mailing Address - Fax:
Practice Address - Street 1:301 LAKE ST
Practice Address - Street 2:BOX 370
Practice Address - City:DALLAS
Practice Address - State:PA
Practice Address - Zip Code:18612-1008
Practice Address - Country:US
Practice Address - Phone:570-675-9588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE008009225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant