Provider Demographics
NPI:1235713009
Name:SMITH, LOGAN DONOVON (BS)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:DONOVON
Last Name:SMITH
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19916 OLD OWEN RD # 152
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-9778
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 E MAIN ST STE 209
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1519
Practice Address - Country:US
Practice Address - Phone:360-485-0820
Practice Address - Fax:949-404-8981
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2021-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care Coordinator