Provider Demographics
NPI:1013437508
Name:LOGAN, RICKY JERMAINE
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:JERMAINE
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 1:129 NORTH KING STREET
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:129 NORTH KING STREET
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060
Practice Address - Country:US
Practice Address - Phone:413-585-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor