Provider Demographics
NPI:1750034120
Name:LOGAN, BRENT (MA, RBT)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:
Last Name:LOGAN
Suffix:
Gender:M
Credentials:MA, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3322 WILLIAM JOHNSTON LN APT 32
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22026-2163
Mailing Address - Country:US
Mailing Address - Phone:703-434-0879
Mailing Address - Fax:
Practice Address - Street 1:3322 WILLIAM JOHNSTON LN APT 32
Practice Address - Street 2:
Practice Address - City:DUMFRIES
Practice Address - State:VA
Practice Address - Zip Code:22026-2163
Practice Address - Country:US
Practice Address - Phone:703-434-0879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VABACB724383106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician