Provider Demographics
NPI:1548594435
Name:LOGAN, HALEY DURRETTE (DC)
Entity Type:Individual
Prefix:DR
First Name:HALEY
Middle Name:DURRETTE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:HALEY
Other - Middle Name:DURRETTE
Other - Last Name:LAUCKEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:704 THIMBLE SHOALS
Mailing Address - Street 2:STE. 200
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602
Mailing Address - Country:US
Mailing Address - Phone:757-825-1100
Mailing Address - Fax:
Practice Address - Street 1:593 ABERDEEN RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23661
Practice Address - Country:US
Practice Address - Phone:757-825-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556746111N00000X
MIL1605238111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
021504P62Medicare UPIN