Provider Demographics
NPI:1750020582
Name:LOGAN, KERIE (CCHT)
Entity Type:Individual
Prefix:
First Name:KERIE
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:CCHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21081
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97307-1081
Mailing Address - Country:US
Mailing Address - Phone:503-584-1227
Mailing Address - Fax:
Practice Address - Street 1:958 CLOVERLEAF LN NE
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4606
Practice Address - Country:US
Practice Address - Phone:503-584-1227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVH17969171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR197625594OtherBUSINESS REGISTRY