Provider Demographics
NPI:1649817230
Name:PHIPPS, KATIE MARIE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:MARIE
Last Name:PHIPPS
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:PO BOX 683
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:65793-0683
Mailing Address - Country:US
Mailing Address - Phone:573-883-6761
Mailing Address - Fax:417-815-9405
Practice Address - Street 1:2240 COUNTY ROAD 1270
Practice Address - Street 2:
Practice Address - City:WILLOW SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:65793-3393
Practice Address - Country:US
Practice Address - Phone:573-883-6761
Practice Address - Fax:417-815-9405
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-03
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MO2023002798103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CORBT-19-91402OtherREGISTERED BEHAVIOR TECHNICIAN
MO730122799Medicaid