Healthcare Provider Details

I. General information

NPI: 1659591097
Provider Name (Legal Business Name): KATHLEEN M PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CENTER STREET
MORIARTY NM
87035-0000
US

IV. Provider business mailing address

PO BOX 2000
MORIARTY NM
87035-2000
US

V. Phone/Fax

Practice location:
  • Phone: 505-832-5817
  • Fax: 505-832-5918
Mailing address:
  • Phone: 505-832-5817
  • Fax: 505-832-5918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI-05054
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: