Provider Demographics
NPI:1407081052
Name:KELLOGG, TARA J (BS, DC)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:J
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:BS, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:596 BROADWAY STE 302
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-3396
Mailing Address - Country:US
Mailing Address - Phone:302-275-6439
Mailing Address - Fax:
Practice Address - Street 1:209 W 13TH ST APT 16
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-7751
Practice Address - Country:US
Practice Address - Phone:302-275-6439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX011678111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor