MEDICARE: MS. KATE ANN PHILLIPS CADC1

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	040736	OR
2	171M00000X	Case Manager/Care Coordinator	040736	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A6520711	OTHER	CA	CADCII
2	040736	OTHER	OR	CADC

General Provider Information

NPI Number	:	1093852261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KATE ANN PHILLIPS CADC1

Provider Business Mailing Address
First Line	:	3340 KEMPER ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-4906
Country	:	US
Telephone Number	:	619-523-8121
Fax Number	:	619-523-8742

Provider Business Practice Location Address
First Line	:	3340 KEMPER ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-4906
Country	:	US
Telephone Number	:	619-523-8121
Fax Number	:	619-523-8742

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	03/19/2012

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