Provider Demographics
NPI:1558783324
Name:LOGAN, KARA (MA)
Entity Type:Individual
Prefix:
First Name:KARA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4707
Mailing Address - Country:US
Mailing Address - Phone:865-325-3109
Mailing Address - Fax:
Practice Address - Street 1:331 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-4707
Practice Address - Country:US
Practice Address - Phone:865-325-3109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-14
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN101YM0800X
101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional