MEDICARE: LEVI LOGAN BCBA

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1821793936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEVI LOGAN BCBA

Provider Business Mailing Address
First Line	:	60 LYNOAK CV STE D
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-2988
Country	:	US
Telephone Number	:	731-693-9902
Fax Number	:

Provider Business Practice Location Address
First Line	:	60 LYNOAK CV STE D
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-2988
Country	:	US
Telephone Number	:	731-693-9902
Fax Number	:

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

Provider Enumeration Date	:	03/31/2023
Last Update Date	:	03/31/2023

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Directions to “ LEVI LOGAN BCBA” Practice Location

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