Provider Demographics
NPI:1316020837
Name:LOGAN, LINDA L (LPCMH)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:L
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LPCMH
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:L
Other - Last Name:WILLKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCMH
Mailing Address - Street 1:115 E HAVENS AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-4461
Mailing Address - Country:US
Mailing Address - Phone:605-999-6162
Mailing Address - Fax:605-942-7300
Practice Address - Street 1:115 E HAVENS AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-4461
Practice Address - Country:US
Practice Address - Phone:605-999-6162
Practice Address - Fax:605-942-7300
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPCMH2101101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6575790Medicaid