MEDICARE: LOGAN GRAY DARKHOLME

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1881432789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOGAN GRAY DARKHOLME

Provider Business Mailing Address
First Line	:	368 BROADWAY
Second Line	:	STE 201
City	:	KINGSTON
State	:	NY
Zip	:	12401-5160
Country	:	US
Telephone Number	:	845-768-0232
Fax Number	:

Provider Business Practice Location Address
First Line	:	368 BROADWAY
Second Line	:	STE 201
City	:	KINGSTON
State	:	NY
Zip	:	12401-5160
Country	:	US
Telephone Number	:	845-768-0232
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2024
Last Update Date	:	07/16/2024

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