Provider Demographics
NPI:1548207277
Name:KELLOGG, GLENDA KAYE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:GLENDA
Middle Name:KAYE
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4523 W BELLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-0530
Mailing Address - Country:US
Mailing Address - Phone:573-823-9783
Mailing Address - Fax:
Practice Address - Street 1:4523 W BELLVIEW DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-0530
Practice Address - Country:US
Practice Address - Phone:573-823-9783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0034601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO496845934Medicaid
MO496845934Medicaid