Basic Information
| Provider Information | |||||||||
| NPI: | 1093469926 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | RHONDA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7712 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711377712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187733520 | ||||||||
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| Practice Location | |||||||||
| Address1: | 609 REDWATER RD. | ||||||||
| Address2: | |||||||||
| City: | WAKE VILLAGE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035018032 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2022 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 834685225 | 05 | TX | MEDICAID |