Healthcare Provider Details

I. General information

NPI: 1154004869
Provider Name (Legal Business Name): LOGAN MOODY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 3RD ST STE B
SAN RAFAEL CA
94901-3580
US

IV. Provider business mailing address

361 3RD ST STE B
SAN RAFAEL CA
94901-3580
US

V. Phone/Fax

Practice location:
  • Phone: 415-572-0813
  • Fax:
Mailing address:
  • Phone: 415-572-0813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number384134
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number31043
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: