1558544635 NPI number — MISS BRENDA RENEE LOGAN LMFT, CEAP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558544635 NPI number — MISS BRENDA RENEE LOGAN LMFT, CEAP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOGAN
Provider First Name:
BRENDA
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LMFT, CEAP
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:
1558544635
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 513283
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90051-1283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-791-8305
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1225 W 190TH ST
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
GARDENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90248-4320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-753-7763
Provider Business Practice Location Address Fax Number:
310-538-5518
Provider Enumeration Date:
12/11/2007

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: 101YM0800X , with the licence number:  MFT 45015 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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