Provider Demographics
NPI:1144239757
Name:KELLOGG, DUANE JR (DMIN)
Entity Type:Individual
Prefix:DR
First Name:DUANE
Middle Name:
Last Name:KELLOGG
Suffix:JR
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 WAKEMAN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-5120
Mailing Address - Country:US
Mailing Address - Phone:203-255-5078
Mailing Address - Fax:
Practice Address - Street 1:8 WAKEMAN RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5120
Practice Address - Country:US
Practice Address - Phone:203-255-5078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELP2116101YP1600X
CT001832101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral