Provider Demographics
NPI:1447793401
Name:LOGAN, AUDREY MCCALL
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:MCCALL
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 1:3604 REMORA DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-3843
Mailing Address - Country:US
Mailing Address - Phone:859-421-0474
Mailing Address - Fax:
Practice Address - Street 1:3479 BUCKHORN DRIVE
Practice Address - Street 2:STE 106
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40515
Practice Address - Country:US
Practice Address - Phone:859-246-7282
Practice Address - Fax:859-273-2184
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-23
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health