Provider Demographics
NPI:1245587583
Name:LOGAN, REGINALD (LMHC)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:LOGAN
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 GATLIN DR
Mailing Address - Street 2:
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32955-7022
Mailing Address - Country:US
Mailing Address - Phone:321-243-5938
Mailing Address - Fax:
Practice Address - Street 1:3311 GATLIN DR
Practice Address - Street 2:SUITE 102
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32955-7022
Practice Address - Country:US
Practice Address - Phone:321-243-5938
Practice Address - Fax:321-610-7947
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14191101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health