Provider Demographics
NPI:1578214904
Name:KELLOGG, CARLIE ALEXANDRA
Entity type:Individual
Prefix:
First Name:CARLIE
Middle Name:ALEXANDRA
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 VERNON ST
Mailing Address - Street 2:
Mailing Address - City:EMINENCE
Mailing Address - State:KY
Mailing Address - Zip Code:40019-1441
Mailing Address - Country:US
Mailing Address - Phone:502-889-1015
Mailing Address - Fax:
Practice Address - Street 1:212 VERNON ST
Practice Address - Street 2:
Practice Address - City:EMINENCE
Practice Address - State:KY
Practice Address - Zip Code:40019-1441
Practice Address - Country:US
Practice Address - Phone:502-889-1015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY259937106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist