Provider Demographics
NPI:1902354871
Name:KELLOGG, STACIE (MPT)
Entity Type:Individual
Prefix:MS
First Name:STACIE
Middle Name:
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 6TH ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-5034
Mailing Address - Country:US
Mailing Address - Phone:605-394-1813
Mailing Address - Fax:605-394-6766
Practice Address - Street 1:21 SAINT JOSEPH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-2822
Practice Address - Country:US
Practice Address - Phone:605-394-1813
Practice Address - Fax:605-394-6766
Is Sole Proprietor?:No
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD11682251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics