Provider Demographics
NPI:1093334757
Name:HAYES, LOGAN TAYLOR (MHW)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:TAYLOR
Last Name:HAYES
Suffix:
Gender:M
Credentials:MHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2642 BERTELLA RD
Mailing Address - Street 2:
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-4076
Mailing Address - Country:US
Mailing Address - Phone:916-221-8697
Mailing Address - Fax:
Practice Address - Street 1:768 PLEASANT VALLEY RD STE 201
Practice Address - Street 2:
Practice Address - City:DIAMOND SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95619-9260
Practice Address - Country:US
Practice Address - Phone:916-221-8697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator