Provider Demographics
NPI:1861538779
Name:FOSTER, PHILLIP ARTHUR (PHD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:ARTHUR
Last Name:FOSTER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 ELDORADO SUITE 102
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704
Mailing Address - Country:US
Mailing Address - Phone:309-706-3190
Mailing Address - Fax:309-588-4115
Practice Address - Street 1:808 S ELDORADO RD STE 102
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-6071
Practice Address - Country:US
Practice Address - Phone:309-706-3190
Practice Address - Fax:309-588-4115
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180000680101YP2500X
IL071007538103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional