Healthcare Provider Details

I. General information

NPI: 1609063742
Provider Name (Legal Business Name): PHILLIP PARKER M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 10/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1459 MAIN ST.
TUNICA MS
38676
US

IV. Provider business mailing address

PO BOX 1046
CLARKSDALE MS
38614-1046
US

V. Phone/Fax

Practice location:
  • Phone: 662-363-5999
  • Fax: 662-627-5240
Mailing address:
  • Phone: 662-627-7267
  • Fax: 662-627-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCH0540
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: