Provider Demographics
NPI:1821020736
Name:LOGAN, JAMES R (PHD, MP)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:LOGAN
Suffix:
Gender:M
Credentials:PHD, MP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1927 WHITE ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-6357
Mailing Address - Country:US
Mailing Address - Phone:318-613-9981
Mailing Address - Fax:
Practice Address - Street 1:41 LORD OF LORDS AVE
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-2113
Practice Address - Country:US
Practice Address - Phone:318-641-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA702103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1146579Medicaid
LA1146579Medicaid