Healthcare Provider Details

I. General information

NPI: 1013652197
Provider Name (Legal Business Name): LATOSIA RENA-DENISE LOGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2022
Last Update Date: 02/19/2026
Certification Date: 02/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45964 BRENTWOOD ST
MACOMB MI
48042-5410
US

IV. Provider business mailing address

45964 BRENTWOOD ST
MACOMB MI
48042-5410
US

V. Phone/Fax

Practice location:
  • Phone: 586-948-0665
  • Fax:
Mailing address:
  • Phone: 586-948-0665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6451019460
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: