Provider Demographics
NPI:1417654807
Name:PHIPPS, MARY MELISSA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MELISSA
Last Name:PHIPPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 S DIXON ST
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-3268
Mailing Address - Country:US
Mailing Address - Phone:317-270-0584
Mailing Address - Fax:
Practice Address - Street 1:2900 S DIXON ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-3268
Practice Address - Country:US
Practice Address - Phone:317-270-0584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
INRBT-22-207546OtherBEHAVIOR ANALYST CERTIFICATION BOARD