Provider Demographics
NPI:1053713131
Name:KELLOGG, ELLEN (MACCC-SLP)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 748
Mailing Address - Street 2:
Mailing Address - City:FLAGLER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32136-0748
Mailing Address - Country:US
Mailing Address - Phone:585-202-2745
Mailing Address - Fax:
Practice Address - Street 1:393 PALM COAST PKWY SW
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4773
Practice Address - Country:US
Practice Address - Phone:585-202-2745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-21
Last Update Date:2014-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10093235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist