Provider Demographics
NPI:1518595859
Name:PHILLIPS, KELLY (PHD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 HANNUM AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-6553
Mailing Address - Country:US
Mailing Address - Phone:310-410-9504
Mailing Address - Fax:
Practice Address - Street 1:5800 HANNUM AVE STE 105
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-6553
Practice Address - Country:US
Practice Address - Phone:310-410-9504
Practice Address - Fax:310-410-9507
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94023963390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program