Provider Demographics
NPI:1740737840
Name:LOGAN, STEPHANIE
Entity Type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:
Last Name:LOGAN
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 1:515 W GREENDALE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-4516
Mailing Address - Country:US
Mailing Address - Phone:586-335-9755
Mailing Address - Fax:
Practice Address - Street 1:515 W GREENDALE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-4516
Practice Address - Country:US
Practice Address - Phone:586-335-9755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other