Healthcare Provider Details

I. General information

NPI: 1093504664
Provider Name (Legal Business Name): MRS. KENZY PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2025
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 LENOX POINTE NE STE A
ATLANTA GA
30324-3103
US

IV. Provider business mailing address

15 PARKWOOD DR
COVINGTON GA
30016-8514
US

V. Phone/Fax

Practice location:
  • Phone: 678-824-6590
  • Fax: 678-228-1258
Mailing address:
  • Phone: 678-906-1374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: