Provider Demographics
NPI:1417582438
Name:KELLOGG, TRISHA LEIGH
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:LEIGH
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 E ARROW HWY BLDG C
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4987
Mailing Address - Country:US
Mailing Address - Phone:909-609-2002
Mailing Address - Fax:
Practice Address - Street 1:1260 E ARROW HWY BLDG C
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4987
Practice Address - Country:US
Practice Address - Phone:909-609-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI28880120101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)