Provider Demographics
NPI:1225646300
Name:LOGAN, TARA (MA, LLPC, LLMFT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MA, LLPC, LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1533 N PARK ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-1806
Mailing Address - Country:US
Mailing Address - Phone:269-422-0565
Mailing Address - Fax:
Practice Address - Street 1:157 S KALAMAZOO MALL STE 250
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-4828
Practice Address - Country:US
Practice Address - Phone:269-422-0565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401018406101YP2500X
MI4151000532106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional