Provider Demographics
NPI:1396459038
Name:O'HANDLEY, LOGAN MARCUS
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:MARCUS
Last Name:O'HANDLEY
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 1:207 POOR VALLEY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-7319
Mailing Address - Country:US
Mailing Address - Phone:423-647-7506
Mailing Address - Fax:
Practice Address - Street 1:207 POOR VALLEY CREEK RD
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37857-7319
Practice Address - Country:US
Practice Address - Phone:423-647-7506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician