Provider Demographics
NPI:1790922151
Name:KELLOGG, CONNIE L (LCMHC)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 CONCORD AVE
Mailing Address - Street 2:SUITE #3
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-1513
Mailing Address - Country:US
Mailing Address - Phone:802-748-9555
Mailing Address - Fax:
Practice Address - Street 1:231 CONCORD AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-1513
Practice Address - Country:US
Practice Address - Phone:802-748-9555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068-0000761101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health