Healthcare Provider Details

I. General information

NPI: 1982200515
Provider Name (Legal Business Name): WILLIAM PHILLIPS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 E RIVER ST
ELYRIA OH
44035-5902
US

IV. Provider business mailing address

3452 TUTTLE AVE
CLEVELAND OH
44111-3027
US

V. Phone/Fax

Practice location:
  • Phone: 440-329-7596
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0028421
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN.456208
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: