Provider Demographics
NPI:1669282836
Name:LOGAN, MICHAELA (EDS)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2433 CRESTONE DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-2802
Mailing Address - Country:US
Mailing Address - Phone:775-771-5130
Mailing Address - Fax:
Practice Address - Street 1:2433 CRESTONE DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-2802
Practice Address - Country:US
Practice Address - Phone:775-771-5130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV88241103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool