Provider Demographics
NPI:1477854206
Name:KELLOGG, MOLLY (RD, LCSW)
Entity Type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:RD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E SEDGWICK ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-1850
Mailing Address - Country:US
Mailing Address - Phone:215-843-8258
Mailing Address - Fax:
Practice Address - Street 1:100 E SEDGWICK ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-1850
Practice Address - Country:US
Practice Address - Phone:215-843-8258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW-0139061041C0700X
PADN-000906133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered