1174530117 NPI number — REKITA CHARNELLE JUSTICE LOGAN LCSW

Table of content: REKITA CHARNELLE JUSTICE LOGAN LCSW (NPI 1174530117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174530117 NPI number — REKITA CHARNELLE JUSTICE LOGAN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JUSTICE LOGAN
Provider First Name:
REKITA
Provider Middle Name:
CHARNELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174530117
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 VETERANS MEMORIAL DR
Provider Second Line Business Mailing Address:
CENTRAL TEXAS VETERANS HEALTH CARE SYSTEM
Provider Business Mailing Address City Name:
TEMPLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 VETERANS MEMORIAL DR
Provider Second Line Business Practice Location Address:
CENTRAL TEXAS VETERANS HEALTH CARE SYSTEM
Provider Business Practice Location Address City Name:
TEMPLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-743-0711
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  38302 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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