Healthcare Provider Details

I. General information

NPI: 1083508394
Provider Name (Legal Business Name): LOGAN WAHL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2463 E GALA ST
MERIDIAN ID
83642-5209
US

IV. Provider business mailing address

213 LODGE POLE DR
MIDDLETON ID
83644-4800
US

V. Phone/Fax

Practice location:
  • Phone: 208-955-7333
  • Fax:
Mailing address:
  • Phone: 541-215-5923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: