Provider Demographics
NPI:1679525570
Name:KELLOGG, JULIA A (PT, CHT)
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:A
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:PT, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 DEWEY AVE NW
Mailing Address - Street 2:STE 300
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-7335
Mailing Address - Country:US
Mailing Address - Phone:616-356-5000
Mailing Address - Fax:616-356-5001
Practice Address - Street 1:1428 W MEYER RD
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3499
Practice Address - Country:US
Practice Address - Phone:636-887-3660
Practice Address - Fax:636-887-3661
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01829225100000X
MO96110001712251H1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00609549OtherRAILROAD MEDICARE
MO12325956OtherCAQH ID
MO990301643Medicare PIN
MO147410022Medicare PIN