Provider Demographics
NPI:1255779161
Name:PHILLIPS, MITZI ELAINE (PTA)
Entity type:Individual
Prefix:
First Name:MITZI
Middle Name:ELAINE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6985 NUGGETT DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-7994
Mailing Address - Country:US
Mailing Address - Phone:828-443-3185
Mailing Address - Fax:
Practice Address - Street 1:6985 NUGGETT DR
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-7994
Practice Address - Country:US
Practice Address - Phone:828-443-3185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1883305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1883OtherPHYCSICAL THERAPIST ASSISTANT