Provider Demographics
NPI:1629296215
Name:LOGAN, DARLENE LOUISE (OTR)
Entity Type:Individual
Prefix:MS
First Name:DARLENE
Middle Name:LOUISE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2897 HIGHWAY 31
Mailing Address - Street 2:
Mailing Address - City:AXTELL
Mailing Address - State:TX
Mailing Address - Zip Code:76624-1208
Mailing Address - Country:US
Mailing Address - Phone:254-722-4815
Mailing Address - Fax:
Practice Address - Street 1:2897 HIGHWAY 31
Practice Address - Street 2:
Practice Address - City:AXTELL
Practice Address - State:TX
Practice Address - Zip Code:76624-1208
Practice Address - Country:US
Practice Address - Phone:254-722-4815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-22
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107828174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist