Provider Demographics
NPI:1407216534
Name:LOGAN, KALEB MERCEDES
Entity Type:Individual
Prefix:
First Name:KALEB
Middle Name:MERCEDES
Last Name:LOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 E 48TH PL N
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74126-3423
Mailing Address - Country:US
Mailing Address - Phone:918-637-7692
Mailing Address - Fax:
Practice Address - Street 1:1631 E 48TH PL N
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74126-3423
Practice Address - Country:US
Practice Address - Phone:918-637-7692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor