Healthcare Provider Details

I. General information

NPI: 1396731394
Provider Name (Legal Business Name): MARILYN EPSTEIN KELLOGG PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

852 COMMERCE AVE
LONGVIEW WA
98632-2406
US

IV. Provider business mailing address

PO BOX 3002
LONGVIEW WA
98632-0302
US

V. Phone/Fax

Practice location:
  • Phone: 360-501-3750
  • Fax: 360-501-3755
Mailing address:
  • Phone: 360-414-2048
  • Fax: 360-575-6749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00001047
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: