Healthcare Provider Details

I. General information

NPI: 1306848940
Provider Name (Legal Business Name): RANDALL WALLACE PHILLIPS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

367B N PARKWAY
JACKSON TN
38305-2865
US

IV. Provider business mailing address

26 CHANDLERS CV
JACKSON TN
38305-6913
US

V. Phone/Fax

Practice location:
  • Phone: 731-668-2277
  • Fax:
Mailing address:
  • Phone: 731-660-6015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT 000050
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: