Provider Demographics
NPI:1841034972
Name:LOGAN, SHYANNA
Entity type:Individual
Prefix:
First Name:SHYANNA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 THORNBERRY LN
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:NY
Mailing Address - Zip Code:12144-8448
Mailing Address - Country:US
Mailing Address - Phone:518-706-9109
Mailing Address - Fax:
Practice Address - Street 1:108 THORNBERRY LN
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:NY
Practice Address - Zip Code:12144-8448
Practice Address - Country:US
Practice Address - Phone:518-706-9109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool