Provider Demographics
NPI:1780299610
Name:GORDON, LOGAN THOMAS (LAC)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:THOMAS
Last Name:GORDON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 880
Mailing Address - Street 2:
Mailing Address - City:SAINT IGNATIUS
Mailing Address - State:MT
Mailing Address - Zip Code:59865-0880
Mailing Address - Country:US
Mailing Address - Phone:406-745-3525
Mailing Address - Fax:
Practice Address - Street 1:35401 MISSION DR
Practice Address - Street 2:
Practice Address - City:SAINT IGNATIUS
Practice Address - State:MT
Practice Address - Zip Code:59865-7791
Practice Address - Country:US
Practice Address - Phone:406-745-3525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-ACLC-LIC-37537101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)