Basic Information
| Provider Information | |||||||||
| NPI: | 1093708208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | J. DEAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S.,L.C.P.C.,N.C.C. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1200 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624013032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173477179 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1200 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624013032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173477179 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 180005312 | IL | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 39002212A | IN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 180-005312 | 01 | IL | LCPC | OTHER | 370912882 | 05 | IL | MEDICAID | 202794 | 01 | NATIONAL CERTIFICATION | OTHER | 39002212A | 01 | IN | INDIANA PROFESSIONAL LICENSING | OTHER |