Healthcare Provider Details

I. General information

NPI: 1063935419
Provider Name (Legal Business Name): LOGAN WURSTER MA, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4348 E GRAND RIVER AVE
HOWELL MI
48843-8554
US

IV. Provider business mailing address

15510 1/2 DAYTON RD
MONROE MI
48161-3783
US

V. Phone/Fax

Practice location:
  • Phone: 734-929-2620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401001623
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: