Healthcare Provider Details

I. General information

NPI: 1558067124
Provider Name (Legal Business Name): SHELBY LOGAN MA, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/06/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 KIMBARK ST STE 200
LONGMONT CO
80501-5585
US

IV. Provider business mailing address

500 KIMBARK ST STE 200
LONGMONT CO
80501-5585
US

V. Phone/Fax

Practice location:
  • Phone: 303-651-1515
  • Fax: 720-652-0408
Mailing address:
  • Phone: 303-651-1515
  • Fax: 720-652-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0018485
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: