Provider Demographics
NPI:1154097111
Name:KIRBY, BRENT LOGAN (MA)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:LOGAN
Last Name:KIRBY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 305
Mailing Address - Street 2:
Mailing Address - City:SUMMITVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46070-0305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17345 N 150 E
Practice Address - Street 2:
Practice Address - City:SUMMITVILLE
Practice Address - State:IN
Practice Address - Zip Code:46070-9121
Practice Address - Country:US
Practice Address - Phone:907-690-1701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral