Provider Demographics
NPI:1700327178
Name:LOGAN, KIKI
Entity Type:Individual
Prefix:
First Name:KIKI
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 E PARK RD
Mailing Address - Street 2:
Mailing Address - City:ELLENBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28040-7621
Mailing Address - Country:US
Mailing Address - Phone:828-305-3870
Mailing Address - Fax:
Practice Address - Street 1:245 E PARK RD
Practice Address - Street 2:
Practice Address - City:ELLENBORO
Practice Address - State:NC
Practice Address - Zip Code:28040-7621
Practice Address - Country:US
Practice Address - Phone:828-305-3870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency