Provider Demographics
NPI:1225316656
Name:LOGAN, MICHAEL ODELL
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ODELL
Last Name:LOGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3455 WEST CRAIG RD. UNIT C
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031
Mailing Address - Country:US
Mailing Address - Phone:702-612-5844
Mailing Address - Fax:702-479-7134
Practice Address - Street 1:3455 W CRAIG RD STE C
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-5119
Practice Address - Country:US
Practice Address - Phone:702-612-5844
Practice Address - Fax:702-479-7134
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV103K00000X103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst