Healthcare Provider Details

I. General information

NPI: 1215450622
Provider Name (Legal Business Name): MARGARET KELLOGG, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 07/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 CLEVELAND AVE S STE 1B
SAINT PAUL MN
55105-1255
US

IV. Provider business mailing address

1374 EDGCUMBE RD
SAINT PAUL MN
55116-1726
US

V. Phone/Fax

Practice location:
  • Phone: 612-638-7233
  • Fax: 612-699-4105
Mailing address:
  • Phone: 612-638-7233
  • Fax: 651-699-4105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: MARGARET B KELLOGG
Title or Position: OWNER
Credential: MA LP
Phone: 612-638-7233