Healthcare Provider Details

I. General information

NPI: 1992328850
Provider Name (Legal Business Name): LOGAN MONTGOMERY LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2020
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date: 06/05/2025
Reactivation Date: 06/25/2025

III. Provider practice location address

2220 WEALTHY ST SE
GRAND RAPIDS MI
49506-3016
US

IV. Provider business mailing address

925 LAKE MICHIGAN DR NW
GRAND RAPIDS MI
49504-5642
US

V. Phone/Fax

Practice location:
  • Phone: 616-277-7533
  • Fax:
Mailing address:
  • Phone: 231-670-1221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451024366
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: