Provider Demographics
NPI:1043085871
Name:LOGAN, RICHARD HENRY (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:HENRY
Last Name:LOGAN
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8649 NEW ENGLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:IL
Mailing Address - Zip Code:60459-2216
Mailing Address - Country:US
Mailing Address - Phone:708-548-8308
Mailing Address - Fax:
Practice Address - Street 1:8649 NEW ENGLAND AVE
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459-2216
Practice Address - Country:US
Practice Address - Phone:708-548-8308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.028575363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health