Provider Demographics
NPI:1003380643
Name:PHILLIPS, KAITLAN (LMSW)
Entity Type:Individual
Prefix:
First Name:KAITLAN
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:RISING SUN
Mailing Address - State:MD
Mailing Address - Zip Code:21911-1545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 RIDGE RD
Practice Address - Street 2:
Practice Address - City:RISING SUN
Practice Address - State:MD
Practice Address - Zip Code:21911-1545
Practice Address - Country:US
Practice Address - Phone:302-824-9636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker