Provider Demographics
NPI:1801181540
Name:LOGAN, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LOGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 NORTH DAVIDSON STREET
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-2346
Mailing Address - Country:US
Mailing Address - Phone:931-434-2484
Mailing Address - Fax:
Practice Address - Street 1:709 NORTH DAVIDSON STREET
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2346
Practice Address - Country:US
Practice Address - Phone:931-434-2484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health