Provider Demographics
NPI:1083770689
Name:PHELPS, MARILYN DERDEN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:DERDEN
Last Name:PHELPS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 MOTLOW RD
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-7804
Mailing Address - Country:US
Mailing Address - Phone:615-390-1153
Mailing Address - Fax:931-454-1217
Practice Address - Street 1:928 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2332
Practice Address - Country:US
Practice Address - Phone:931-454-2242
Practice Address - Fax:931-454-1217
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000042331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical