Provider Demographics
NPI:1790394906
Name:PHILLIPS, KATELYN RENEE
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:RENEE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 HEALTHCARE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARROLL
Mailing Address - State:IL
Mailing Address - Zip Code:61053-1461
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1122 HEALTHCARE DR
Practice Address - Street 2:
Practice Address - City:MOUNT CARROLL
Practice Address - State:IL
Practice Address - Zip Code:61053-1461
Practice Address - Country:US
Practice Address - Phone:815-244-1376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health