Provider Demographics
NPI:1902488695
Name:KELLOGG, COURTNEY SUE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:SUE
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 1:20890 KENBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-8041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20890 KENBRIDGE CT
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-8041
Practice Address - Country:US
Practice Address - Phone:612-355-8865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst