Healthcare Provider Details

I. General information

NPI: 1316865025
Provider Name (Legal Business Name): KIMANI LOGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 BIRNIE AVE
SPRINGFIELD MA
01107-1104
US

IV. Provider business mailing address

42 WRIGHT ST
PALMER MA
01069-1156
US

V. Phone/Fax

Practice location:
  • Phone: 413-439-2189
  • Fax: 413-451-0037
Mailing address:
  • Phone: 844-243-4357
  • Fax: 413-451-0037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: