Provider Demographics
NPI:1780107433
Name:LOGAN, MARK ALAN (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:LOGAN
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 N DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-1949
Mailing Address - Country:US
Mailing Address - Phone:310-751-1080
Mailing Address - Fax:844-941-1989
Practice Address - Street 1:538 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-1949
Practice Address - Country:US
Practice Address - Phone:310-751-1080
Practice Address - Fax:844-941-1989
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013193363LP0808X
CANP95013193363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health