Healthcare Provider Details

I. General information

NPI: 1366557878
Provider Name (Legal Business Name): ROBIN HENDERSON-LOGAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD NAVAL HOSPITAL
CAMP LEJEUNE NC
28547-2538
US

IV. Provider business mailing address

100 BREWSTER BLVD NAVAL HOSPITAL
CAMP LEJEUNE NC
28547-2538
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-4159
  • Fax: 910-450-4194
Mailing address:
  • Phone: 910-450-4159
  • Fax: 910-450-4194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number3229
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number010028-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: