Healthcare Provider Details

I. General information

NPI: 1972165884
Provider Name (Legal Business Name): LOGAN TAYLOR BUSWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7701 SIX FORKS RD
RALEIGH NC
27615-5050
US

IV. Provider business mailing address

3420 S BEAVER LN
RALEIGH NC
27604-6074
US

V. Phone/Fax

Practice location:
  • Phone: 800-701-0498
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1159
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: