Healthcare Provider Details

I. General information

NPI: 1467902809
Provider Name (Legal Business Name): DEREK PHILLIPS PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W LINCOLN AVE
CHARLESTON IL
61920-2467
US

IV. Provider business mailing address

PO BOX 372
MATTOON IL
61938-0372
US

V. Phone/Fax

Practice location:
  • Phone: 217-238-4042
  • Fax: 217-238-4053
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071.009513
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number074.000012
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: