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General NPI Number Information
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NPI Number | 1417453275
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Entity Type | Individual
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Provider Name | COLLEEN RUA LOGAN PHD, LPC-S
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Gender | Female
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Dates
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Enumeration Date | 04/02/2018
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Last Update Date | 06/20/2018
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Provider Practice Location Address
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Address Line | 610 OLD CAMPBELL RD STE 112
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City | RICHARDSON
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State | TX
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Zip | 75080-3379
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Country | US
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Telephone | 469-831-7618
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Fax |
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Provider Business Mailing Address
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Address Line | 610 OLD CAMPBELL RD STE 112
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City | RICHARDSON
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State | TX
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Zip | 75080-3379
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Country | US
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Telephone | 469-831-7618
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 65609
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License Number State | TX
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