Healthcare Provider Details

I. General information

NPI: 1104547702
Provider Name (Legal Business Name): BREANNA LOGAN MANK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BREANNA LOGAN CLUBB

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 LOCUST ST
RED BUD IL
62278-1374
US

IV. Provider business mailing address

605 S BENTON ST
NEW ATHENS IL
62264-1608
US

V. Phone/Fax

Practice location:
  • Phone: 618-282-6251
  • Fax:
Mailing address:
  • Phone: 618-550-9969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1383039
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: