Basic Information
| Provider Information | |||||||||
| NPI: | 1487271938 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOGAN | ||||||||
| FirstName: | LINDA | ||||||||
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| Credential: | BCBA, LBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3817 CARLYLE CT | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224089200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402146883 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11 HOPE RD STE 215 | ||||||||
| Address2: | |||||||||
| City: | STAFFORD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 225547287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402251020 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2020 | ||||||||
| LastUpdateDate: | 07/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0133001341 | VA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.