Healthcare Provider Details

I. General information

NPI: 1003629304
Provider Name (Legal Business Name): MICHAEL DEWAYNE LOGAN MSW, MCJ, BCJ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2025
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W MONTGOMERY ST
GAFFNEY SC
29341-1773
US

IV. Provider business mailing address

906 SPRING ST
GAFFNEY SC
29340-2930
US

V. Phone/Fax

Practice location:
  • Phone: 864-487-2721
  • Fax:
Mailing address:
  • Phone: 864-425-6675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: