Healthcare Provider Details

I. General information

NPI: 1336940535
Provider Name (Legal Business Name): JULIE PHILLIPS
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2025
Last Update Date: 03/24/2025
Certification Date: 03/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 COUNTRY CLUB RD
FAIRMONT WV
26554-1306
US

IV. Provider business mailing address

1539 COUNTRY CLUB RD
FAIRMONT WV
26554-1306
US

V. Phone/Fax

Practice location:
  • Phone: 304-366-9100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA002947
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: