Healthcare Provider Details

I. General information

NPI: 1366520637
Provider Name (Legal Business Name): ELISHA LOGAN MA,LPC, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 TURTLE BAY DR
BRANFORD CT
06405-4980
US

IV. Provider business mailing address

655 PARK AVE
BRIDGEPORT CT
06604-4611
US

V. Phone/Fax

Practice location:
  • Phone: 760-672-0361
  • Fax:
Mailing address:
  • Phone: 203-338-0669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDP00383
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6181
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: