Healthcare Provider Details

I. General information

NPI: 1073146387
Provider Name (Legal Business Name): LOGAN SINCAVAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2020
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 OLD FIELD LN
ST AUGUSTINE FL
32092-1928
US

IV. Provider business mailing address

143 OLD FIELD LN
ST AUGUSTINE FL
32092-1928
US

V. Phone/Fax

Practice location:
  • Phone: 561-309-4219
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: LOGAN SINCAVAGE
Title or Position: CEO
Credential: LMHC
Phone: 561-309-4219