Provider Demographics
NPI:1699323451
Name:PHILLIPS, DANIELLE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
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 1:96 VALLEY LN APT 7
Mailing Address - Street 2:
Mailing Address - City:EAGLE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56024-4612
Mailing Address - Country:US
Mailing Address - Phone:507-508-9305
Mailing Address - Fax:
Practice Address - Street 1:220 E MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3574
Practice Address - Country:US
Practice Address - Phone:507-345-7012
Practice Address - Fax:507-388-6937
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician