Provider Demographics
NPI:1275152910
Name:MOUNT LOGAN CLINIC LLC
Entity Type:Organization
Organization Name:MOUNT LOGAN CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:435-750-6300
Mailing Address - Street 1:246 E 1260 N
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-7501
Mailing Address - Country:US
Mailing Address - Phone:435-750-6300
Mailing Address - Fax:435-753-8995
Practice Address - Street 1:246 E 1260 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-7501
Practice Address - Country:US
Practice Address - Phone:435-750-6300
Practice Address - Fax:435-753-8995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-13
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty