Provider Demographics
NPI:1760950620
Name:PHILLIPS, MARIANKE (RBT)
Entity Type:Individual
Prefix:
First Name:MARIANKE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RBT
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 74849
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-4849
Mailing Address - Country:US
Mailing Address - Phone:907-406-8813
Mailing Address - Fax:
Practice Address - Street 1:326 DRIVEWAY ST STE 100
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-2807
Practice Address - Country:US
Practice Address - Phone:907-521-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKRBT-18-70070106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician