Provider Demographics
NPI:1508475914
Name:LOGSTON, HOLLY MARIEL
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:MARIEL
Last Name:LOGSTON
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 1:309 ROGERS AVE
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-4227
Mailing Address - Country:US
Mailing Address - Phone:918-658-8075
Mailing Address - Fax:
Practice Address - Street 1:309 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4227
Practice Address - Country:US
Practice Address - Phone:918-658-8078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator