Healthcare Provider Details

I. General information

NPI: 1699127977
Provider Name (Legal Business Name): JEORGE L LOGAN LCDCIIII
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 07/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S EDWIN C MOSES BLVD
DAYTON OH
45417-3424
US

IV. Provider business mailing address

601 S EDWIN C MOSES BLVD
DAYTON OH
45417-3424
US

V. Phone/Fax

Practice location:
  • Phone: 937-734-8333
  • Fax:
Mailing address:
  • Phone: 937-734-8333
  • Fax: 937-734-4343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDC.151219-3
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: