Provider Demographics
NPI:1174956452
Name:PHIPPS, KATHY S (LCDCIII)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:S
Last Name:PHIPPS
Suffix:
Gender:F
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4470 N RANGELINE RD
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45318-9773
Mailing Address - Country:US
Mailing Address - Phone:937-418-8075
Mailing Address - Fax:
Practice Address - Street 1:4470 N RANGELINE RD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:OH
Practice Address - Zip Code:45318-9773
Practice Address - Country:US
Practice Address - Phone:937-418-8075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH091120101YA0400X
171M00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker