Provider Demographics
NPI:1790841716
Name:LOGAN, SANDRA L (MA MED LPC)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:L
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MA MED LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 E 5TH STREET
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204
Mailing Address - Country:US
Mailing Address - Phone:704-375-3545
Mailing Address - Fax:704-375-3632
Practice Address - Street 1:1801 E 5TH STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204
Practice Address - Country:US
Practice Address - Phone:704-373-9444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4715103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist