MEDICARE: GRAYSON D. PHILLIPS SR. PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	21754	TX

General Provider Information

NPI Number	:	1013938695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRAYSON D. PHILLIPS SR. PH.D.

Provider Business Mailing Address
First Line	:	540 CLEAR SPRINGS DR
Second Line	:
City	:	MESQUITE
State	:	TX
Zip	:	75150-8025
Country	:	US
Telephone Number	:	972-979-4563
Fax Number	:	214-890-4019

Provider Business Practice Location Address
First Line	:	7502 GREENVILLE AVE.
Second Line	:	SUITE 500
City	:	DALLAS
State	:	TX
Zip	:	75231-3812
Country	:	US
Telephone Number	:	214-361-6019
Fax Number	:	214-890-4019

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	07/08/2007

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