Provider Demographics
NPI:1831508183
Name:EVERETT, LOGAN KEVIN (MA, LMFT)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:KEVIN
Last Name:EVERETT
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9493 MAPLELEAF CIR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-8524
Mailing Address - Country:US
Mailing Address - Phone:765-401-0921
Mailing Address - Fax:
Practice Address - Street 1:7425 E 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1207
Practice Address - Country:US
Practice Address - Phone:317-474-6448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001943A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN47-1561586OtherN/A