Healthcare Provider Details

I. General information

NPI: 1104337989
Provider Name (Legal Business Name): LOGAN NICOLETTE MASSEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2017
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PALENCIA VILLAGE DR # C-105164
ST AUGUSTINE FL
32095-8549
US

IV. Provider business mailing address

120 PALENCIA VILLAGE DR
ST AUGUSTINE FL
32095-8549
US

V. Phone/Fax

Practice location:
  • Phone: 904-201-9129
  • Fax: 615-694-3915
Mailing address:
  • Phone: 904-201-9129
  • Fax: 615-694-3915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: