Provider Demographics
NPI:1093443111
Name:ANDERSON, LOGAN VICTORIA
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:VICTORIA
Last Name:ANDERSON
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 1:1299 FARNAM ST STE 300
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68102-1857
Mailing Address - Country:US
Mailing Address - Phone:402-235-1973
Mailing Address - Fax:
Practice Address - Street 1:16726 PATRICK AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68116-2545
Practice Address - Country:US
Practice Address - Phone:402-686-5335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE0103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE0Medicaid