Healthcare Provider Details

I. General information

NPI: 1205606159
Provider Name (Legal Business Name): GREGORY J LOGAN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2024
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 SW COLUMBIA ST STE D2
BEND OR
97702-1020
US

IV. Provider business mailing address

296 SW COLUMBIA ST STE D2
BEND OR
97702-1020
US

V. Phone/Fax

Practice location:
  • Phone: 541-550-7940
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC11530
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: