Provider Demographics
NPI:1528604485
Name:HUMITZ, LOGAN (CCC)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:HUMITZ
Suffix:
Gender:F
Credentials:CCC
Other - Prefix:
Other - First Name:LOGAN
Other - Middle Name:
Other - Last Name:VINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC
Mailing Address - Street 1:38935 ANN ARBOR RD STE 150
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3397
Mailing Address - Country:US
Mailing Address - Phone:580-880-5855
Mailing Address - Fax:248-780-2947
Practice Address - Street 1:38935 ANN ARBOR RD STE 150
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-3397
Practice Address - Country:US
Practice Address - Phone:248-886-9540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101006250235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist