Provider Demographics
NPI:1497980783
Name:KELLOGG, MARY JANE
Entity Type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY JANE
Other - Middle Name:
Other - Last Name:CAVAZOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2117 E TYLER AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-7211
Mailing Address - Country:US
Mailing Address - Phone:956-440-0580
Mailing Address - Fax:956-440-0584
Practice Address - Street 1:2117 E TYLER AVE
Practice Address - Street 2:SUITE B
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-7211
Practice Address - Country:US
Practice Address - Phone:956-440-0580
Practice Address - Fax:956-440-0584
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX333752355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX33375OtherSTATE LICENSE