Provider Demographics
NPI:1518230622
Name:KELLOGG, TRECIA A
Entity Type:Individual
Prefix:
First Name:TRECIA
Middle Name:A
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 1:115 LAWTON ST APT 5H
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10705-4636
Mailing Address - Country:US
Mailing Address - Phone:914-450-2399
Mailing Address - Fax:
Practice Address - Street 1:115 LAWTON ST APT 5H
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10705-4636
Practice Address - Country:US
Practice Address - Phone:914-450-2399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY72-070938101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health