Provider Demographics
NPI:1679265144
Name:PHILLIPS, KATHRYN KRYSTAL
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:KRYSTAL
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:KRYSTAL
Other - Last Name:MERICA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6472 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-2062
Mailing Address - Country:US
Mailing Address - Phone:951-965-0566
Mailing Address - Fax:
Practice Address - Street 1:6809 INDIANA AVE STE 154
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4221
Practice Address - Country:US
Practice Address - Phone:951-441-7649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician