Provider Demographics
NPI:1669117057
Name:CONGDON, LOGAN SEBASTIAN
Entity type:Individual
Prefix:MR
First Name:LOGAN
Middle Name:SEBASTIAN
Last Name:CONGDON
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 1:1059 SAN JUAN DR SE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3452
Mailing Address - Country:US
Mailing Address - Phone:616-802-4890
Mailing Address - Fax:
Practice Address - Street 1:1115 BALL AVE NE BLDG B
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5904
Practice Address - Country:US
Practice Address - Phone:616-451-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-01
Last Update Date:2022-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor