Provider Demographics
NPI:1205972171
Name:LOGAN, GREGORY DAVID (MS, SLP)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:DAVID
Last Name:LOGAN
Suffix:
Gender:M
Credentials:MS, SLP
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 5236
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-5236
Mailing Address - Country:US
Mailing Address - Phone:406-270-1949
Mailing Address - Fax:
Practice Address - Street 1:219 MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2347
Practice Address - Country:US
Practice Address - Phone:407-270-1949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP653235Z00000X
MT1194235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME008640OtherANTHEM BCBS
ME300740099Medicaid