Provider Demographics
NPI:1073810644
Name:KIM LOGAN COMMUNICATIONS CLINIC INC
Entity Type:Organization
Organization Name:KIM LOGAN COMMUNICATIONS CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:O
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-664-4900
Mailing Address - Street 1:3011 W GRAND BLVD
Mailing Address - Street 2:SUITE 423
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3096
Mailing Address - Country:US
Mailing Address - Phone:313-664-4900
Mailing Address - Fax:313-664-4901
Practice Address - Street 1:3011 W GRAND BLVD
Practice Address - Street 2:SUITE 423
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3096
Practice Address - Country:US
Practice Address - Phone:313-664-4900
Practice Address - Fax:313-664-4901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-17
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401001940101YP2500X
103TA0400X, 103TC2200X, 103TF0000X, 103TP2701X, 106H00000X
MI6301011558103TC0700X, 1041S0200X
MI68010682361041C0700X
MD12068248235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty