Healthcare Provider Details

I. General information

NPI: 1073401808
Provider Name (Legal Business Name): ELLIOT PHILLIPS MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2025
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 DAVIS ST STE 815
EVANSTON IL
60201-4655
US

IV. Provider business mailing address

5013 N WOLCOTT AVE APT 3W
CHICAGO IL
60640-2621
US

V. Phone/Fax

Practice location:
  • Phone: 312-640-7740
  • Fax:
Mailing address:
  • Phone: 917-459-3004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: