Provider Demographics
NPI:1790301604
Name:LOGAN, LEAH L (LCMHC-A)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:L
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LCMHC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 SANTE CIR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-9215
Mailing Address - Country:US
Mailing Address - Phone:704-534-3560
Mailing Address - Fax:
Practice Address - Street 1:635 COX RD STE B
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3441
Practice Address - Country:US
Practice Address - Phone:704-691-7561
Practice Address - Fax:704-691-7563
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15587101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCA15587OtherNC LICENSE