Provider Demographics
NPI:1669009536
Name:LOGAN, KYLE JOSEPH (HIS)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:JOSEPH
Last Name:LOGAN
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118-2655
Mailing Address - Country:US
Mailing Address - Phone:860-810-9614
Mailing Address - Fax:
Practice Address - Street 1:310 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-1315
Practice Address - Country:US
Practice Address - Phone:475-221-7856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT432237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist