Provider Demographics
NPI:1770689861
Name:KELLOGG, SARAH LYN (DPT)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:LYN
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 CONKEY AVE
Mailing Address - Street 2:BOX 136
Mailing Address - City:NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:13815-1756
Mailing Address - Country:US
Mailing Address - Phone:607-432-1558
Mailing Address - Fax:607-432-1566
Practice Address - Street 1:121 STOCKTON AVE
Practice Address - Street 2:
Practice Address - City:WALTON
Practice Address - State:NY
Practice Address - Zip Code:13856-1430
Practice Address - Country:US
Practice Address - Phone:607-432-1558
Practice Address - Fax:607-432-1566
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028605225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ37P61Medicare PIN
NYP00405068Medicare PIN
NYRB2076Medicare PIN