Basic Information
| Provider Information | |||||||||
| NPI: | 1003359860 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHELPS | ||||||||
| FirstName: | KAYLIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 COLUMBUS AVENUE | ||||||||
| Address2: | CREDENTIALING SPECIALIST | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033174 | ||||||||
| FaxNumber: | 2035036515 | ||||||||
| Practice Location | |||||||||
| Address1: | 93 EDWARDS ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065113933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037721270 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2016 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 3587 | CT | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.