Healthcare Provider Details

I. General information

NPI: 1427455229
Provider Name (Legal Business Name): BONNIE PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2014
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 N. FODALE AVE.
SOUTHPORT NC
28461-2815
US

IV. Provider business mailing address

3001 SPRING FOREST RD
RALEIGH NC
27616-2815
US

V. Phone/Fax

Practice location:
  • Phone: 910-457-0830
  • Fax:
Mailing address:
  • Phone: 919-424-5086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5242
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: