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NPI Code Detail

MEDICARE: MISS DOMINIQUE YVETTE LOGAN

MEDICARE: MISS DOMINIQUE YVETTE 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
1103K00000XBehavior Analyst

General Provider Information

NPI Number : 1740574375
Entity Type Code : Individual
Provider Name (Legal Business Name) : MISS DOMINIQUE YVETTE LOGAN
Provider Business Mailing Address
First Line : 3455 W CRAIG RD STE C
Second Line :
City : NORTH LAS VEGAS
State : NV
Zip : 89032-5119
Country : US
Telephone Number : 702-518-9337
Fax Number : 702-479-7134
Provider Business Practice Location Address
First Line : 3455 W CRAIG RD STE C
Second Line :
City : NORTH LAS VEGAS
State : NV
Zip : 89032-5119
Country : US
Telephone Number : 702-518-9337
Fax Number : 702-479-7134
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/31/2011
Last Update Date : 05/31/2011

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Directions to “ MISS DOMINIQUE YVETTE LOGAN ” Practice Location

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