MEDICARE: LOGAN WHITE TIJERINA M.A., LPC

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	101YP2500X	Professional Counselor	8627	LA

General Provider Information

NPI Number	:	1104793124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOGAN WHITE TIJERINA M.A., LPC

Provider Business Mailing Address
First Line	:	1541 BELFIELD RD
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70611-4715
Country	:	US
Telephone Number	:	337-427-8230
Fax Number	:	337-270-9427

Provider Business Practice Location Address
First Line	:	1541 BELFIELD RD
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70611-4715
Country	:	US
Telephone Number	:	337-427-8230
Fax Number	:	337-270-9427

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

Provider Enumeration Date	:	10/22/2025
Last Update Date	:	10/22/2025

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