MEDICARE: LIBERTY ROSE LOGAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171400000X	Health & Wellness Coach	230090840	CA

General Provider Information

NPI Number	:	1003745332
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIBERTY ROSE LOGAN

Provider Business Mailing Address
First Line	:	6050 CALMFIELD AVE
Second Line	:
City	:	AGOURA HILLS
State	:	CA
Zip	:	91301-2104
Country	:	US
Telephone Number	:	818-991-4940
Fax Number	:

Provider Business Practice Location Address
First Line	:	6050 CALMFIELD AVE
Second Line	:
City	:	AGOURA HILLS
State	:	CA
Zip	:	91301-2104
Country	:	US
Telephone Number	:	818-991-4940
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2026
Last Update Date	:	06/03/2026

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Directions to “ LIBERTY ROSE LOGAN ” Practice Location

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