Healthcare Provider Details

I. General information

NPI: 1487465704
Provider Name (Legal Business Name): LOGAN RENE NICKERSON CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2025
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 WOLF CREEK BLVD STE 2&3
DOVER DE
19901-4967
US

IV. Provider business mailing address

114 LOGAN DR
DOVER DE
19901-1583
US

V. Phone/Fax

Practice location:
  • Phone: 302-744-8474
  • Fax:
Mailing address:
  • Phone: 302-505-0384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2346
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: