Provider Demographics
NPI:1972273787
Name:LOGAN, TENDERLY REAY (PPSC; LEP; APCC)
Entity Type:Individual
Prefix:
First Name:TENDERLY
Middle Name:REAY
Last Name:LOGAN
Suffix:
Gender:F
Credentials:PPSC; LEP; APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 CLOVER VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:UPPER LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95485-9220
Mailing Address - Country:US
Mailing Address - Phone:707-275-2338
Mailing Address - Fax:
Practice Address - Street 1:675 CLOVER VALLEY RD
Practice Address - Street 2:
Practice Address - City:UPPER LAKE
Practice Address - State:CA
Practice Address - Zip Code:95485-9220
Practice Address - Country:US
Practice Address - Phone:707-275-2338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3183103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool