Provider Demographics
NPI:1134342199
Name:LOGAN, ROBERT A (LPC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:LOGAN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 RAWLINS STREET
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-1900
Mailing Address - Country:US
Mailing Address - Phone:307-275-2483
Mailing Address - Fax:307-426-4799
Practice Address - Street 1:4025 RAWLINS STREET
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1900
Practice Address - Country:US
Practice Address - Phone:307-275-2483
Practice Address - Fax:307-426-4799
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-455101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106662500Medicaid
WY310021OtherBCBS OF WYOMING
WY106662500Medicaid