Provider Demographics
NPI:1811083652
Name:FLORES, PHILIP JOHN (PHD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:JOHN
Last Name:FLORES
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 1:6065 LAKE FORREST DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328
Mailing Address - Country:US
Mailing Address - Phone:404-250-9340
Mailing Address - Fax:770-579-1967
Practice Address - Street 1:6065 LAKE FORREST DR
Practice Address - Street 2:SUITE 150
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328
Practice Address - Country:US
Practice Address - Phone:404-250-9340
Practice Address - Fax:770-579-1967
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000897103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
62TCCFWMedicare ID - Type Unspecified