Healthcare Provider Details

I. General information

NPI: 1760908263
Provider Name (Legal Business Name): LOGAN OLIVIA WILDER-INGRAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2017
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 FAIRGROVE AVE
HAMILTON OH
45011-1930
US

IV. Provider business mailing address

1910 FAIRGROVE AVE
HAMILTON OH
45011-1930
US

V. Phone/Fax

Practice location:
  • Phone: 513-494-4679
  • Fax:
Mailing address:
  • Phone: 513-494-4679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII.161933
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.167891
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.162260
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.164220
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2204204
License Number StateOH
# 6
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2204204
License Number StateOH
# 7
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.2505581
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: