MEDICARE: KIM LOGAN COMMUNICATIONS CLINIC INC

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	L1118869	MI

General Provider Information

NPI Number	:	1134318066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIM LOGAN COMMUNICATIONS CLINIC INC

Provider Business Mailing Address
First Line	:	8313 GRAND RIVER AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48204-2231
Country	:	US
Telephone Number	:	313-898-8200
Fax Number	:	313-898-2232

Provider Business Practice Location Address
First Line	:	8313 GRAND RIVER AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48204-2231
Country	:	US
Telephone Number	:	313-898-8200
Fax Number	:	313-898-2232

Authorized Official
Title or Position	:	CEO
Name	:	DR. KIM JANISSE LOGAN
Credential	:	PH.D,SPL
Telephone Number	:	313-898-8200

Provider Enumeration Date	:	10/16/2007
Last Update Date	:	09/29/2010

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