Healthcare Provider Details

I. General information

NPI: 1700899366
Provider Name (Legal Business Name): CONSTANCE ADAMS LOGAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 WOOLWORTH AVE
OMAHA NE
68105-1850
US

IV. Provider business mailing address

4101 WOOLWORTH AVE
OMAHA NE
68105-1850
US

V. Phone/Fax

Practice location:
  • Phone: 402-346-8800
  • Fax: 402-449-0667
Mailing address:
  • Phone: 402-346-8800
  • Fax: 402-449-0667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number573
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: