Provider Demographics
NPI:1619293735
Name:PHILLIPS, MARK A (LICSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 TECHNOLOGY WAY STE 1E3
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03060-3245
Mailing Address - Country:US
Mailing Address - Phone:603-886-5565
Mailing Address - Fax:603-886-8642
Practice Address - Street 1:65 TECHNOLOGY WAY STE 1E3
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060
Practice Address - Country:US
Practice Address - Phone:603-886-5565
Practice Address - Fax:603-886-8642
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1134341041C0700X
NH18521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical