Provider Demographics
NPI:1003207259
Name:LOGAN, DIANE (PHD, CSAC)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:PHD, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5488
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96745-5488
Mailing Address - Country:US
Mailing Address - Phone:808-785-5443
Mailing Address - Fax:
Practice Address - Street 1:75-5751 KUAKINI HWY STE 104
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1705
Practice Address - Country:US
Practice Address - Phone:808-326-5629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-10
Last Update Date:2020-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2055-19101YA0400X
HI2055-19I101YA0400X
HIPSY-1550103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)