Provider Demographics
NPI:1861817421
Name:PHILLIPS, CRAIG ROBERT
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:ROBERT
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PHYSIS COUNSELING LLC
Mailing Address - Street 2:770 SOUTH MAIN ST SUITE 24
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935
Mailing Address - Country:US
Mailing Address - Phone:920-960-8051
Mailing Address - Fax:
Practice Address - Street 1:PHYSIS COUNSELING LLC
Practice Address - Street 2:770 SOUTH MAIN ST SUITE 24
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-3556
Practice Address - Country:US
Practice Address - Phone:920-960-8051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5936-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1861817421Medicaid
WI100036100Medicaid