Healthcare Provider Details

I. General information

NPI: 1124953476
Provider Name (Legal Business Name): MR. CHARLES ALVIN PHILLIPS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E 115TH ST
CHICAGO IL
60628-5014
US

IV. Provider business mailing address

259 E 115TH ST
CHICAGO IL
60628-5014
US

V. Phone/Fax

Practice location:
  • Phone: 773-339-7394
  • Fax: 773-339-7394
Mailing address:
  • Phone: 773-981-7816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.118110
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: