Provider Demographics
NPI:1689095846
Name:PHILLIPS, KATHLEEN (MA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:J
Other - Last Name:HENNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:354 AVENUE A
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1940
Mailing Address - Country:US
Mailing Address - Phone:631-816-1106
Mailing Address - Fax:
Practice Address - Street 1:225 BROADHOLLOW RD STE 402
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4899
Practice Address - Country:US
Practice Address - Phone:631-385-7780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-13
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No174H00000XOther Service ProvidersHealth Educator