Healthcare Provider Details

I. General information

NPI: 1215622683
Provider Name (Legal Business Name): LAUREN AMBER LOGSDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 W LANE RD
MACHESNEY PARK IL
61115-1625
US

IV. Provider business mailing address

9500 BORMET DR STE 304
MOKENA IL
60448-8399
US

V. Phone/Fax

Practice location:
  • Phone: 815-469-1500
  • Fax:
Mailing address:
  • Phone: 815-469-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.023192
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: