Provider Demographics
NPI:1770108235
Name:LOGUE, CORYN (EDS)
Entity type:Individual
Prefix:
First Name:CORYN
Middle Name:
Last Name:LOGUE
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66102-5550
Mailing Address - Country:US
Mailing Address - Phone:816-777-8064
Mailing Address - Fax:
Practice Address - Street 1:295 S 10TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66102-5550
Practice Address - Country:US
Practice Address - Phone:816-777-8064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3754799592103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool