Provider Demographics
NPI:1598193393
Name:PHILLIPS, ELAINE MICHELLE (LMBT)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:MICHELLE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4722 BENTTREE DR
Mailing Address - Street 2:
Mailing Address - City:MC LEANSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27301-8107
Mailing Address - Country:US
Mailing Address - Phone:336-339-8672
Mailing Address - Fax:
Practice Address - Street 1:4722 BENTTREE DR
Practice Address - Street 2:
Practice Address - City:MC LEANSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27301-8107
Practice Address - Country:US
Practice Address - Phone:336-339-8672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-15
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10742225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist