Provider Demographics
NPI:1720795354
Name:LOGAN, DEZURAY
Entity Type:Individual
Prefix:
First Name:DEZURAY
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 1:8815 BERTHA PALMER BLVD APT 2-206
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-5568
Mailing Address - Country:US
Mailing Address - Phone:407-929-7683
Mailing Address - Fax:
Practice Address - Street 1:2111 W SWANN AVE STE 100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2478
Practice Address - Country:US
Practice Address - Phone:813-219-1765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician