Healthcare Provider Details

I. General information

NPI: 1255001053
Provider Name (Legal Business Name): CHRISTINE ANN LOGUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9920 KINCEY AVE STE 150
HUNTERSVILLE NC
28078-2457
US

IV. Provider business mailing address

4235 S STREAM BLVD STE 300
CHARLOTTE NC
28217-0143
US

V. Phone/Fax

Practice location:
  • Phone: 980-785-1113
  • Fax: 980-785-1114
Mailing address:
  • Phone: 980-785-1113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2598
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: