Healthcare Provider Details

I. General information

NPI: 1073810644
Provider Name (Legal Business Name): KIM LOGAN COMMUNICATIONS CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3011 W GRAND BLVD SUITE 423
DETROIT MI
48202-3096
US

IV. Provider business mailing address

3011 W GRAND BLVD SUITE 423
DETROIT MI
48202-3096
US

V. Phone/Fax

Practice location:
  • Phone: 313-664-4900
  • Fax: 313-664-4901
Mailing address:
  • Phone: 313-664-4900
  • Fax: 313-664-4901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301011558
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801068236
License Number StateMI
# 7
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number6301011558
License Number StateMI
# 8
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number12068248
License Number StateMD
# 10
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401001940
License Number StateMI

VIII. Authorized Official

Name: KAREN O ANDERSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 313-664-4900