Provider Demographics
NPI:1619693322
Name:WEBB, LOGAN RUSSELL
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:RUSSELL
Last Name:WEBB
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 1:5902 AYERS ST LOT 248
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78415-2261
Mailing Address - Country:US
Mailing Address - Phone:281-682-4522
Mailing Address - Fax:
Practice Address - Street 1:410 S PADRE ISLAND DR STE 103
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78405-4122
Practice Address - Country:US
Practice Address - Phone:361-881-4788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician