Provider Demographics
NPI:1447297494
Name:MARK, PHYLLIS B (PSYD)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:B
Last Name:MARK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3504 VANN ROAD
Mailing Address - Street 2:STE 100, GRAYSON & ASSOCIATES PC
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3504 VANN ROAD
Practice Address - Street 2:STE 100, GRAYSON & ASSOCIATES PC
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235
Practice Address - Country:US
Practice Address - Phone:205-655-0585
Practice Address - Fax:205-655-0586
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL892103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000034487Medicaid
AL051034487OtherBCBS OF AL
AL000034487Medicare ID - Type Unspecified
S34155Medicare UPIN