MEDICARE: MS. TARA MARIE KELLOGG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MT2003	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023267416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TARA MARIE KELLOGG

Provider Business Mailing Address
First Line	:	3521 W BROWARD BLVD
Second Line	:	3RD FLOOR
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33312-1048
Country	:	US
Telephone Number	:	954-587-1008
Fax Number	:	954-587-0080

Provider Business Practice Location Address
First Line	:	3521 W BROWARD BLVD
Second Line	:	3RD FLOOR
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33312-1048
Country	:	US
Telephone Number	:	954-587-1008
Fax Number	:	954-587-0080

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2008
Last Update Date	:	09/10/2008

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