Provider Demographics
NPI:1609063742
Name:PARKER, PHILLIP (MS)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:
Last Name:PARKER
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1046
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-1046
Mailing Address - Country:US
Mailing Address - Phone:662-627-7267
Mailing Address - Fax:662-627-5240
Practice Address - Street 1:1459 MAIN ST.
Practice Address - Street 2:
Practice Address - City:TUNICA
Practice Address - State:MS
Practice Address - Zip Code:38676
Practice Address - Country:US
Practice Address - Phone:662-363-5999
Practice Address - Fax:662-627-5240
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-03
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSCH0540101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health