Provider Demographics
NPI:1669590949
Name:LOGAN COMMUNITY SERVICES
Entity type:Organization
Organization Name:LOGAN COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LADC
Authorized Official - Phone:405-282-5524
Mailing Address - Street 1:PO BOX 1558
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-1558
Mailing Address - Country:US
Mailing Address - Phone:405-282-5524
Mailing Address - Fax:
Practice Address - Street 1:4710 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-6506
Practice Address - Country:US
Practice Address - Phone:405-282-5524
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100733910AMedicaid