Healthcare Provider Details

I. General information

NPI: 1760064299
Provider Name (Legal Business Name): LOGAN MENTAL HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2021
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 N 200 W
LOGAN UT
84341-1900
US

IV. Provider business mailing address

PO BOX 6415
LOGAN UT
84341-6415
US

V. Phone/Fax

Practice location:
  • Phone: 435-750-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: PAUL S BARNARD
Title or Position: PARTNER
Credential:
Phone: 435-938-8508