Provider Demographics
NPI:1235805466
Name:LOGAN, TATYUNNA TANEA
Entity Type:Individual
Prefix:
First Name:TATYUNNA
Middle Name:TANEA
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 1:2734 LEDO RD STE 13
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-7628
Mailing Address - Country:US
Mailing Address - Phone:229-304-4486
Mailing Address - Fax:
Practice Address - Street 1:2734 LEDO RD STE 13
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-7628
Practice Address - Country:US
Practice Address - Phone:229-304-4485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician