Provider Demographics
NPI:1851578512
Name:LOGAN, DUSTIN M (PHD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:M
Last Name:LOGAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3034
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-3034
Mailing Address - Country:US
Mailing Address - Phone:907-745-5066
Mailing Address - Fax:907-746-2851
Practice Address - Street 1:8201 N MICHAELSON ST
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-8196
Practice Address - Country:US
Practice Address - Phone:907-745-5066
Practice Address - Fax:877-640-1413
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60616291103TC0700X, 103TC0700X
AK121536103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical