Healthcare Provider Details

I. General information

NPI: 1316634819
Provider Name (Legal Business Name): LOGAN ANDERSON-DEARTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 ALBRIGHT RD
KOKOMO IN
46902-3996
US

IV. Provider business mailing address

2701 ALBRIGHT RD
KOKOMO IN
46902-3996
US

V. Phone/Fax

Practice location:
  • Phone: 765-661-9709
  • Fax: 765-573-6769
Mailing address:
  • Phone: 765-438-8515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberRBT-22-245965
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-245965
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: