Healthcare Provider Details

I. General information

NPI: 1023886678
Provider Name (Legal Business Name): TAI LOGAN LEGAGNOUX AMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2023
Last Update Date: 12/13/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

679 S NEW HAMPSHIRE AVE STE 400
LOS ANGELES CA
90005-1355
US

IV. Provider business mailing address

679 S NEW HAMPSHIRE AVE STE 400
LOS ANGELES CA
90005-1355
US

V. Phone/Fax

Practice location:
  • Phone: 213-639-2500
  • Fax:
Mailing address:
  • Phone: 213-639-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT142318
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: