Healthcare Provider Details

I. General information

NPI: 1750244893
Provider Name (Legal Business Name): LOGAN MATHEWS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 INTERNATIONAL PKWY STE 200
LAKE MARY FL
32746-5028
US

IV. Provider business mailing address

36 MONAGHAN WAY
DALLAS GA
30132-0079
US

V. Phone/Fax

Practice location:
  • Phone: 866-610-0580
  • Fax: 866-611-1558
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-496514
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: