Provider Demographics
NPI:1760778971
Name:KELLOGG, EVA ROSE (MA)
Entity Type:Individual
Prefix:MRS
First Name:EVA
Middle Name:ROSE
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:EVA
Other - Middle Name:ROSE
Other - Last Name:BURKLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2323 HEARST AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-1319
Mailing Address - Country:US
Mailing Address - Phone:510-548-7270
Mailing Address - Fax:
Practice Address - Street 1:2323 HEARST AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-1319
Practice Address - Country:US
Practice Address - Phone:510-548-7270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-26
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91070106H00000X
CA76967106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist