Healthcare Provider Details

I. General information

NPI: 1356578876
Provider Name (Legal Business Name): MARY ANN LOGAN MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 06/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 HOSPITAL DR BUILDING 3
MOUNTAIN VIEW CA
94040-4106
US

IV. Provider business mailing address

2500 HOSPITAL DR BUILDING 3
MOUNTAIN VIEW CA
94040-4106
US

V. Phone/Fax

Practice location:
  • Phone: 650-694-7850
  • Fax: 650-968-2340
Mailing address:
  • Phone: 650-694-7850
  • Fax: 650-968-2340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC38623
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: