Provider Demographics
NPI:1417436148
Name:LOGAN, MAKENZIE RAE
Entity Type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:RAE
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 1:2600 ARBORETUM DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-3501
Mailing Address - Country:US
Mailing Address - Phone:402-293-4000
Mailing Address - Fax:
Practice Address - Street 1:1401 HIGH SCHOOL DR
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-3274
Practice Address - Country:US
Practice Address - Phone:402-293-4150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2018010907235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILTFZ826226512OtherBLUECROSS BLUESHIELD OF ILLINOIS