Provider Demographics
NPI:1316026925
Name:LOGSDON, STEVEN A (PHD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:A
Last Name:LOGSDON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2607
Mailing Address - Street 2:
Mailing Address - City:UNIVERSAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78148-1607
Mailing Address - Country:US
Mailing Address - Phone:210-658-6410
Mailing Address - Fax:210-531-7334
Practice Address - Street 1:433 KITTY HAWK RD
Practice Address - Street 2:STE 219
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-3829
Practice Address - Country:US
Practice Address - Phone:210-658-6410
Practice Address - Fax:210-531-7334
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2016-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22560103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0976953-01Medicaid
TX22560OtherTEXAS STATE LICENSE
TX00-BY-34Medicare ID - Type UnspecifiedBCBS-PRIVATE PRACTICE
TX81124PMedicare Oscar/Certification