Healthcare Provider Details

I. General information

NPI: 1104793124
Provider Name (Legal Business Name): LOGAN WHITE TIJERINA M.A., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2025
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 BELFIELD RD
LAKE CHARLES LA
70611-4715
US

IV. Provider business mailing address

1541 BELFIELD RD
LAKE CHARLES LA
70611-4715
US

V. Phone/Fax

Practice location:
  • Phone: 337-427-8230
  • Fax: 337-270-9427
Mailing address:
  • Phone: 337-427-8230
  • Fax: 337-270-9427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8627
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: