Provider Demographics
NPI:1851348833
Name:BARRY, PHILIP (PHD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:BARRY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 E SOUTHERN AVE STE C3
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7609
Mailing Address - Country:US
Mailing Address - Phone:480-839-6264
Mailing Address - Fax:480-839-2115
Practice Address - Street 1:2600 E SOUTHERN AVE STE C3
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7609
Practice Address - Country:US
Practice Address - Phone:480-839-6264
Practice Address - Fax:480-839-2115
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1534103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ078601Medicaid
AZ078601Medicaid