Basic Information
| Provider Information | |||||||||
| NPI: | 1811634553 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHELPS | ||||||||
| FirstName: | IESHA | ||||||||
| MiddleName: | T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 BANKS AVE | ||||||||
| Address2: | |||||||||
| City: | MCADOO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 182372508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887264774 | ||||||||
| FaxNumber: | 5703625112 | ||||||||
| Practice Location | |||||||||
| Address1: | 1081 OAK ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | PITTSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 186403716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887264774 | ||||||||
| FaxNumber: | 5703625112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2022 | ||||||||
| LastUpdateDate: | 05/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225500000X | N | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | 106S00000X | Y |
No ID Information.