Provider Demographics
NPI:1841470556
Name:LOGAN, KIM JANISSE (PHD,LPC,BCPC)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:JANISSE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:PHD,LPC,BCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3011 W. GRAND BLVD.
Mailing Address - Street 2:SUITE 423
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3011
Mailing Address - Country:US
Mailing Address - Phone:313-664-4900
Mailing Address - Fax:313-664-4901
Practice Address - Street 1:3011 W. GRAND BLVD.
Practice Address - Street 2:SUITE 423
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3011
Practice Address - Country:US
Practice Address - Phone:313-664-4900
Practice Address - Fax:313-664-4901
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2437318101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health