Provider Demographics
NPI:1508126129
Name:LOGSDON, MARISA JOY
Entity Type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:JOY
Last Name:LOGSDON
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 1:2013 EARL DR
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-9737
Mailing Address - Country:US
Mailing Address - Phone:517-320-7946
Mailing Address - Fax:
Practice Address - Street 1:2013 EARL DR
Practice Address - Street 2:
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-9737
Practice Address - Country:US
Practice Address - Phone:517-320-7946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-17
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012540101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional