MEDICARE: LOGAN MALLERY

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1316467285
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOGAN MALLERY

Provider Business Mailing Address
First Line	:	4829 E BELTLINE AVE NE STE 310
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9350
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4829 E BELTLINE AVE NE STE 310
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9350
Country	:	US
Telephone Number	:	616-279-6414
Fax Number	:

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

Provider Enumeration Date	:	06/22/2017
Last Update Date	:	12/29/2021

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Directions to “ LOGAN MALLERY ” Practice Location

Language	Start Address	Practice Location

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