Provider Demographics
NPI:1013334515
Name:LOGAN, CLARISSA LYNETTE
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:LYNETTE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44447 10TH ST W
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-3324
Mailing Address - Country:US
Mailing Address - Phone:661-723-2630
Mailing Address - Fax:
Practice Address - Street 1:44349 LOWTREE AVE STE 117
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4167
Practice Address - Country:US
Practice Address - Phone:661-492-5295
Practice Address - Fax:661-524-9101
Is Sole Proprietor?:No
Enumeration Date:2014-03-21
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)