Provider Demographics
NPI:1093852261
Name:PHILLIPS, KATE ANN (CADC1)
Entity Type:Individual
Prefix:MS
First Name:KATE
Middle Name:ANN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:CADC1
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:ANN
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CADCII
Mailing Address - Street 1:3340 KEMPER ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4906
Mailing Address - Country:US
Mailing Address - Phone:619-523-8121
Mailing Address - Fax:619-523-8742
Practice Address - Street 1:3340 KEMPER ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4906
Practice Address - Country:US
Practice Address - Phone:619-523-8121
Practice Address - Fax:619-523-8742
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR040736101YA0400X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA6520711OtherCADCII
OR040736OtherCADC