Provider Demographics
NPI:1962638528
Name:PHILLIPS, KATHLEEN C (MA)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:C
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-4724
Mailing Address - Country:US
Mailing Address - Phone:845-462-6701
Mailing Address - Fax:845-463-1330
Practice Address - Street 1:143 BOARDMAN RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-4870
Practice Address - Country:US
Practice Address - Phone:845-462-6701
Practice Address - Fax:845-462-2731
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY58000865235Z00000X, 251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No251300000XAgenciesLocal Education Agency (LEA)