Provider Demographics
NPI:1306848940
Name:PHILLIPS, RANDALL WALLACE (PHD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:WALLACE
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 1:26 CHANDLERS CV
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-6913
Mailing Address - Country:US
Mailing Address - Phone:731-660-6015
Mailing Address - Fax:
Practice Address - Street 1:367B N PARKWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2865
Practice Address - Country:US
Practice Address - Phone:731-668-2277
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMFT 000050106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist