Provider Demographics
NPI:1801412846
Name:LOGAN, ALICIA JEAN (PLPC)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:JEAN
Last Name:LOGAN
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 HEATHER DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-2507
Mailing Address - Country:US
Mailing Address - Phone:636-233-1698
Mailing Address - Fax:
Practice Address - Street 1:2650 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-1489
Practice Address - Country:US
Practice Address - Phone:314-644-6023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019044976101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health