Provider Demographics
NPI:1235704552
Name:LOGAN, NICOLE L
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:LOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34474 SCOTCH LN APT 4
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44094-2991
Mailing Address - Country:US
Mailing Address - Phone:770-369-3510
Mailing Address - Fax:
Practice Address - Street 1:3214 PROSPECT AVE E
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2614
Practice Address - Country:US
Practice Address - Phone:216-910-9015
Practice Address - Fax:216-910-9015
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH176200101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)