Provider Demographics
NPI:1558336297
Name:PHILLIPS, MARK LYNN (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:LYNN
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21610 PARKER RD
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77377-6037
Mailing Address - Country:US
Mailing Address - Phone:281-255-3970
Mailing Address - Fax:
Practice Address - Street 1:1 RAIDER CIRCLE
Practice Address - Street 2:NORTHBROOK HIGH SCHOOL
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77080
Practice Address - Country:US
Practice Address - Phone:713-365-4430
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT0481174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist