MEDICARE: DR. KELLY PHILLIPS PHD

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	103G00000X	Clinical Neuropsychologist	PSY35802	CA
2	103TC2200X	Clinical Child & Adolescent Psychologist	PSY35802	CA
3	103TC0700X	Clinical Psychologist	PSY35802	CA
4	103TF0200X	Forensic Psychologist	PSY35802	CA

General Provider Information

NPI Number	:	1518595859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY PHILLIPS PHD

Provider Business Mailing Address
First Line	:	11400 W OLYMPIC BLVD STE 660
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-1679
Country	:	US
Telephone Number	:	310-935-0032
Fax Number	:

Provider Business Practice Location Address
First Line	:	11400 W OLYMPIC BLVD STE 660
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-1679
Country	:	US
Telephone Number	:	310-935-0032
Fax Number	:

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

Provider Enumeration Date	:	03/31/2020
Last Update Date	:	05/27/2026

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Directions to “ DR. KELLY PHILLIPS PHD” Practice Location

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