Healthcare Provider Details

I. General information

NPI: 1780682930
Provider Name (Legal Business Name): SUSAN L PHILLIPS PHD CCCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 08/20/2007
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 08/20/2007

III. Provider practice location address

524 HIGHLAND AVENUE
GREENSBORO NC
27402-6170
US

IV. Provider business mailing address

PO BOX 26170 UNCG 300 FERGUSON BUILDING
GREENSBORO NC
27402-6170
US

V. Phone/Fax

Practice location:
  • Phone: 336-334-5184
  • Fax: 336-334-4475
Mailing address:
  • Phone: 336-334-5184
  • Fax: 336-334-4475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number4916
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: