Provider Demographics
NPI:1972677979
Name:PHILLIPS, MARY (MA, LP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 MAIN ST NW APT 220
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-1792
Mailing Address - Country:US
Mailing Address - Phone:612-422-0890
Mailing Address - Fax:
Practice Address - Street 1:633 MAIN ST NW APT 220
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1792
Practice Address - Country:US
Practice Address - Phone:612-422-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2022-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 4021103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN877934100OtherMHCP