Provider Demographics
NPI:1164726824
Name:PHILLIPS, KATIE MARIE (MS)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:MARIE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2339 LAKE PARK DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-3360
Mailing Address - Country:US
Mailing Address - Phone:229-255-3099
Mailing Address - Fax:229-638-6302
Practice Address - Street 1:2339 LAKE PARK DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3360
Practice Address - Country:US
Practice Address - Phone:229-553-0992
Practice Address - Fax:229-638-6302
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA208144244Other208144244