Provider Demographics
NPI:1346762036
Name:LOGAN, ANDREA MICHELLE (LLPC, QMHP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MICHELLE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LLPC, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:882 OAKMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-3710
Mailing Address - Country:US
Mailing Address - Phone:313-961-7990
Mailing Address - Fax:
Practice Address - Street 1:882 OAKMAN BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-3710
Practice Address - Country:US
Practice Address - Phone:313-961-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017658101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional