Provider Demographics
NPI:1275297939
Name:LOGAN, DAVIS (SWLC, MSW)
Entity Type:Individual
Prefix:
First Name:DAVIS
Middle Name:
Last Name:LOGAN
Suffix:
Gender:M
Credentials:SWLC, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 CHARIS LN
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-3516
Mailing Address - Country:US
Mailing Address - Phone:313-802-1073
Mailing Address - Fax:
Practice Address - Street 1:14 CHARIS LN
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-3516
Practice Address - Country:US
Practice Address - Phone:313-802-1073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT441811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical