Provider Demographics
NPI:1740017227
Name:LOGAN, SUSAN LYNN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
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 1:20500 BELSHAW AVE # EXCA1377
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-3506
Mailing Address - Country:US
Mailing Address - Phone:415-989-1017
Mailing Address - Fax:
Practice Address - Street 1:11600 BOSTON IVY LN
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37932-1005
Practice Address - Country:US
Practice Address - Phone:989-430-2025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach