Provider Demographics
NPI:1114947579
Name:LOGAN, NANCY A (PHD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:A
Last Name:LOGAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24123 BOERNE STAGE RD
Mailing Address - Street 2:SUITE 430
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78235-9404
Mailing Address - Country:US
Mailing Address - Phone:210-615-0555
Mailing Address - Fax:210-687-1100
Practice Address - Street 1:24123 BOERNE STAGE RD
Practice Address - Street 2:SUITE 430
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78235-9404
Practice Address - Country:US
Practice Address - Phone:210-615-0555
Practice Address - Fax:210-687-1100
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23696103T00000X
NM614103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00G66COtherBCBS
TX8C8454Medicare PIN