Basic Information
| Provider Information | |||||||||
| NPI: | 1295703924 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOGAN | ||||||||
| FirstName: | JOAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNS LPC | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | LOGAN | ||||||||
| OtherFirstName: | JOAN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6040 W 91ST AVE | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800312905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778384783 | ||||||||
| FaxNumber: | 8773453501 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809077045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194712932 | ||||||||
| FaxNumber: | 7194712932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 02/26/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 234 | CO | N | Behavioral Health & Social Service Providers | Counselor | Professional | 163W00000X | 65018 | CO | N | Nursing Service Providers | Registered Nurse | 364SP0813X | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Geropsychiatric |
ID Information
| ID | Type | State | Issuer | Description | 79652336 | 05 | CO | MEDICAID |