Provider Demographics
NPI:1538215736
Name:PHILLIPS, MARK A (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:PHILLIPS
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 1:5005 STONEMEADE DR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37221-4046
Mailing Address - Country:US
Mailing Address - Phone:615-646-1141
Mailing Address - Fax:615-646-1149
Practice Address - Street 1:7640 HIGHWAY 70 S
Practice Address - Street 2:SUITE 209
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37221-1758
Practice Address - Country:US
Practice Address - Phone:615-646-1141
Practice Address - Fax:615-646-1149
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP1513103G00000X, 103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3686357Medicaid
TN3686357Medicare ID - Type Unspecified