Provider Demographics
NPI:1144886797
Name:PHILLIPS, KRISTIE (MS)
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:KRISTIE
Other - Middle Name:
Other - Last Name:KRUSS, BLISS, YACKEYONNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1338 CARTERET AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3043
Mailing Address - Country:US
Mailing Address - Phone:719-600-1998
Mailing Address - Fax:
Practice Address - Street 1:265 S HARLAN ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226-2261
Practice Address - Country:US
Practice Address - Phone:720-272-1289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-18
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO20191395942OtherCERT OF GOOD STANDING