Provider Demographics
NPI:1922731041
Name:PHILLIP, KATOANH SHARRELL
Entity Type:Individual
Prefix:
First Name:KATOANH
Middle Name:SHARRELL
Last Name:PHILLIP
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 1:1919 GRAYMOUNT WAY
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21040-3015
Mailing Address - Country:US
Mailing Address - Phone:443-680-6839
Mailing Address - Fax:
Practice Address - Street 1:1308 BUSINESS CENTER WAY
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:MD
Practice Address - Zip Code:21040-1504
Practice Address - Country:US
Practice Address - Phone:443-461-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDADT2013101YA0400X
MDADT2039101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)