Provider Demographics
NPI:1073152419
Name:GOOLSBY, LOGAN JAMES I (MA, BA)
Entity Type:Individual
Prefix:MR
First Name:LOGAN
Middle Name:JAMES
Last Name:GOOLSBY
Suffix:I
Gender:M
Credentials:MA, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 MOUNTAIN RAIL DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-3128
Mailing Address - Country:US
Mailing Address - Phone:951-285-0893
Mailing Address - Fax:
Practice Address - Street 1:3365 WYNN RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-8210
Practice Address - Country:US
Practice Address - Phone:702-331-3845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NV103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV103K00000XMedicaid