Healthcare Provider Details

I. General information

NPI: 1689095846
Provider Name (Legal Business Name): KATHLEEN PHILLIPS MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN J HENNES BA

II. Dates (important events)

Enumeration Date: 12/13/2013
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 BROADHOLLOW RD STE 402
MELVILLE NY
11747-4899
US

IV. Provider business mailing address

354 AVENUE A
RONKONKOMA NY
11779-1940
US

V. Phone/Fax

Practice location:
  • Phone: 631-385-7780
  • Fax:
Mailing address:
  • Phone: 631-816-1106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: