Provider Demographics
NPI:1669683520
Name:LOGAN, TINA ANN SR (MFT INTER)
Entity Type:Individual
Prefix:MISS
First Name:TINA
Middle Name:ANN
Last Name:LOGAN
Suffix:SR
Gender:F
Credentials:MFT INTER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 BARRY AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1799
Mailing Address - Country:US
Mailing Address - Phone:310-575-9651
Mailing Address - Fax:
Practice Address - Street 1:8220 S. SAN PEDRO STREET
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003
Practice Address - Country:US
Practice Address - Phone:323-789-5640
Practice Address - Fax:323-789-5648
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF46336106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist