Provider Demographics
NPI:1629235544
Name:LOGSDON, TERRI KATHRYN
Entity Type:Individual
Prefix:MRS
First Name:TERRI
Middle Name:KATHRYN
Last Name:LOGSDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 SW TWIG AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-3031
Mailing Address - Country:US
Mailing Address - Phone:772-340-1130
Mailing Address - Fax:
Practice Address - Street 1:197 SW TWIG AVE
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-3031
Practice Address - Country:US
Practice Address - Phone:772-340-1130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2306255 00Medicaid