Provider Demographics
NPI:1609014802
Name:STOCKARD, PHILLIP DANIEL
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:DANIEL
Last Name:STOCKARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4145 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-5400
Mailing Address - Country:US
Mailing Address - Phone:706-869-7373
Mailing Address - Fax:706-869-7380
Practice Address - Street 1:4145 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-5400
Practice Address - Country:US
Practice Address - Phone:706-869-7373
Practice Address - Fax:706-869-7380
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health