Provider Demographics
NPI:1821147158
Name:KELLOGG, CONNIE (PSYCHOLOGIST)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:
Other - Last Name:SKILLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6756 WALKER AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4213
Mailing Address - Country:US
Mailing Address - Phone:707-823-0143
Mailing Address - Fax:707-823-0143
Practice Address - Street 1:6756 WALKER AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4213
Practice Address - Country:US
Practice Address - Phone:707-823-0143
Practice Address - Fax:707-823-0143
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 8554103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral