Provider Demographics
NPI:1558846410
Name:LOGIE, STEFAN
Entity Type:Individual
Prefix:
First Name:STEFAN
Middle Name:
Last Name:LOGIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2082
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95763-2082
Mailing Address - Country:US
Mailing Address - Phone:831-884-6340
Mailing Address - Fax:
Practice Address - Street 1:848 BLOSSOM ROCK LN
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-7845
Practice Address - Country:US
Practice Address - Phone:831-884-6340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral