Healthcare Provider Details

I. General information

NPI: 1679525570
Provider Name (Legal Business Name): JULIA A KELLOGG PT, CHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 W MEYER RD
WENTZVILLE MO
63385-3499
US

IV. Provider business mailing address

607 DEWEY AVE NW STE 300
GRAND RAPIDS MI
49504-7335
US

V. Phone/Fax

Practice location:
  • Phone: 636-887-3660
  • Fax: 636-887-3661
Mailing address:
  • Phone: 616-356-5000
  • Fax: 616-356-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number01829
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License Number9611000171
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: