Provider Demographics
NPI:1124474424
Name:KELLOGG, MARY LUCY (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY LUCY
Middle Name:
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 MIRASOL DR
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-2339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:490 MIRASOL DR
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-2339
Practice Address - Country:US
Practice Address - Phone:970-342-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0001925235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist