Healthcare Provider Details

I. General information

NPI: 1063871481
Provider Name (Legal Business Name): AKI LOGG CGC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 N PASADENA AVE FL 8
PASADENA CA
91103-3670
US

IV. Provider business mailing address

75 N FAIR OAKS AVE
PASADENA CA
91103-3651
US

V. Phone/Fax

Practice location:
  • Phone: 626-381-5975
  • Fax: 626-564-3311
Mailing address:
  • Phone: 626-381-5975
  • Fax: 626-564-3311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberGC000077
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: