=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295293454
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOGAN AMANDA WOLFF PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2019
-----------------------------------------------------
Last Update Date | 03/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 16TH AVE E
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98112-5226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-323-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 TERAVISTA PKWY APT 1123
-----------------------------------------------------
City | ROUND ROCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78665-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY60905083
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------