Provider Demographics
NPI:1356819445
Name:LOGAN, THERESA C (RDN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:C
Last Name:LOGAN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7621 TREMAYNE PL APT 213
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-7609
Mailing Address - Country:US
Mailing Address - Phone:704-651-6781
Mailing Address - Fax:
Practice Address - Street 1:7621 TREMAYNE PL APT 213
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-7609
Practice Address - Country:US
Practice Address - Phone:704-651-6781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX4428133V00000X
SC1211133V00000X
DCDI100001004133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered