Provider Demographics
NPI:1114647328
Name:PORTER, LOGAN MITCHELL (CL 61310165)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:MITCHELL
Last Name:PORTER
Suffix:
Gender:M
Credentials:CL 61310165
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 21ST CT SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-7036
Mailing Address - Country:US
Mailing Address - Phone:253-777-7269
Mailing Address - Fax:
Practice Address - Street 1:4419 21ST CT SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-7036
Practice Address - Country:US
Practice Address - Phone:253-777-7269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61310165101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty