Provider Demographics
NPI:1972729804
Name:PHILLIPS, LARRY S (MA LCPC)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:S
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MA LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 E 103RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-2807
Mailing Address - Country:US
Mailing Address - Phone:773-721-5065
Mailing Address - Fax:773-734-0264
Practice Address - Street 1:7936 S ESSEX AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617
Practice Address - Country:US
Practice Address - Phone:773-721-5065
Practice Address - Fax:773-734-0264
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional