Basic Information
| Provider Information | |||||||||
| NPI: | 1568468841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRILEY | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7700 OLD BRANCH AVE | ||||||||
| Address2: | STE B105 | ||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207351628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019348811 | ||||||||
| FaxNumber: | 3019349321 | ||||||||
| Practice Location | |||||||||
| Address1: | 7700 OLD BRANCH AVE | ||||||||
| Address2: | STE B105 | ||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207351628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019348811 | ||||||||
| FaxNumber: | 3019349321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 03/03/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/15/2006 | ||||||||
| NPIReactivationDate: | 03/23/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 00628 | MD | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 281092 | 01 | MD | KAISER | OTHER | 38160001 | 01 | DC | BLUE CROSS | OTHER | 414910600 | 05 | MD | MEDICAID | 513212 | 01 | MD | NCPPO | OTHER | 521255282 | 01 | MD | TRICARE | OTHER | G074PL | 01 | MD | BLUE CROSS | OTHER | 460568000 | 01 | MD | MAGELLAN | OTHER | 289607 | 01 | MD | MAMSI/ALLIANCE/MDIPA/OP | OTHER |