Provider Demographics
NPI:1760869572
Name:LOGSDON-DOUGHERTY, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:LOGSDON-DOUGHERTY
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 1:809 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-2959
Mailing Address - Country:US
Mailing Address - Phone:307-632-7993
Mailing Address - Fax:307-632-1330
Practice Address - Street 1:3001 HENDERSON DR STE N
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5840
Practice Address - Country:US
Practice Address - Phone:307-632-7993
Practice Address - Fax:307-632-1330
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator