Healthcare Provider Details

I. General information

NPI: 1376466235
Provider Name (Legal Business Name): KENZIE MICHELLE PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CHAMPAIGN: 4108 FIELDSTONE RD SUITE A
CHAMPAIGN IL
61822
US

IV. Provider business mailing address

CHAMPAIGN: 4108 FIELDSTONE RD SUITE A
CHAMPAIGN IL
61822
US

V. Phone/Fax

Practice location:
  • Phone: 217-516-7618
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: