Provider Demographics
NPI:1073843157
Name:LOGAN, CARRIE
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 PONDEROSA TRL
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:AR
Mailing Address - Zip Code:71929-6191
Mailing Address - Country:US
Mailing Address - Phone:501-865-3496
Mailing Address - Fax:
Practice Address - Street 1:711 CLINTON ST
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-5921
Practice Address - Country:US
Practice Address - Phone:870-246-7928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#P8293235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist