Provider Demographics
NPI:1891723052
Name:KELLOGG, JOAN (MA, MA, LCPC)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:MA, MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 S COOK ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-4369
Mailing Address - Country:US
Mailing Address - Phone:847-382-2286
Mailing Address - Fax:
Practice Address - Street 1:202 S COOK ST
Practice Address - Street 2:SUITE 210
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-4369
Practice Address - Country:US
Practice Address - Phone:847-382-2286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180003236101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04923422OtherBLUE SHIELD PROVIDER #